Missing PEG tube found at the ileocecal valve

Percutaneous endoscopic gastrostomy (PEG) tubes are indicated in cases of oropharyngeal or esophageal dysphagia to allow alimentation. Complications are superficial and minor, however obstruction in the setting of PEG migration has been noted. Most obstructions remain proximal, localized to the pyloric or pre-pyloric region, though distal migration to the large intestine, including the cecum, have been noted. Here we present a case of an elderly gentleman with advanced dementia complicated by oropharyngeal dysphagia who presented in the context of a missing PEG tube without adjunctive symptoms. Initial imaging and Esophagogastroduodenoscopy were unremarkable and a repeat PEG tube was placed. Thereafter, repeat imaging demonstrated an oval-shaped foreign object within the right lower quadrant concerning for a migrated original PEG tube, which was confirmed by Computed Tomography with migration to the ileocecal valve. Colonoscopy was subsequently performed with PEG tube retrieval. This case highlights the need to maintain a high index of suspicion for distal PEG tube migration even in the absence of overt symptomatology to prevent further complications such as small or large bowel obstruction.