Duodenal perforation due to compression necrosis by the tip of percutaneous endoscopic gastrostomy tube

Percutaneous endoscopic gastrostomy (PEG) is a common and safe procedure for enteral nutrition. There are few reports concerning its complications. We managed a 31-y-old bedridden case with punched out duodenal perforation without inflammation, from which the tip of the PEG tube protruded. Simple x-ray and computed tomography showed incarceration of the balloon in the duodenal bulb and extravasation of the tip of the tube. We performed simple closure with omental patching for duodenal perforation. Postoperative gastrointestinal fiberscopy on the 11th day revealed scar phase. Some PEG tubes have a balloon, which can prevent the removal of the tube, fix the position of the tube, and prevent the leakage of gastric contents from fistula. However, in our case, the inflated balloon was transferred into the duodenal bulb according to gastric strong peristalsis. This pathophysiologic mechanism is the same as ball bulb syndrome, which is known as gastroduodenal obstruction by incarceration of the gastric submucosal tumor. There is a risk of wedging of the inflated balloon of the PEG tube and perforation of the duodenum. We must not insert the tube too deeply, must not continue to inflate the balloon for a long time, and must check its position using a stethoscope, simple x-ray examination, or ultrasound.