Diarrhea Caused by the Displacement of Percutaneous Endoscopic Gastrostomy Tube Tip Into the Duodenum: A Rare Case

Percutaneous endoscopic gastrostomy (PEG) is a widely used procedure for patients with dysphagia and inadequate oral intake. Although PEG offers numerous benefits, complications can occur. Here, we present an unusual case of a 68-year-old woman who developed persistent diarrhea following a routine PEG tube exchange. Despite treatment attempts, her symptoms persisted, prompting further investigation. Abdominal computed tomography (CT) revealed the unexpected displacement of the PEG tube tip into the duodenum. Repositioning of the tube tip into the stomach resolved the diarrhea, and the patient was discharged without recurrence. Diarrhea is a common gastrointestinal side effect in patients receiving enteral nutrition through a PEG tube, typically attributed to multiple factors. However, to our knowledge, this is the first reported case of diarrhea resulting from a PEG tube tip straying into the duodenum. The patient did not undergo any changes in enteral preparation or receive medications known to cause diarrhea. The identification of the tube misplacement was incidental during the CT scan, underscoring the importance of imaging studies in refractory cases. While previous reports indicate no significant difference in diarrhea occurrence between duodenal and gastric feeding, our findings suggest that the presence of the PEG tube tip in the duodenum may contribute to diarrhea in some patients. This case highlights the potential role of CT imaging in diagnosing the cause of persistent diarrhea in PEG-fed individuals. Further accumulation of cases is necessary to establish the significance of duodenal tube placement as a cause of diarrhea during PEG procedures. In conclusion, this case report emphasizes the importance of considering tube misplacement as a potential cause of refractory diarrhea in patients receiving enteral nutrition through a PEG tube. The use of abdominal CT imaging can be valuable in identifying such misplacements and guiding appropriate interventions. Further research is needed to validate these findings and explore the clinical implications for the management of PEG-related diarrhea.