Gastric Antral Perforation Caused by a Percutaneous Endoscopic Gastrojejunostomy Tube: A Case Report

Percutaneous endoscopic gastrojejunostomy (PEG-J) is used when gastric feeding via percutaneous endoscopic gastrostomy (PEG) is poorly tolerated due to gastroesophageal reflux or delayed gastric emptying. Gastrointestinal perforation related to PEG-J has been reported mainly in infants; gastric perforation in adults is extremely rare. We report a case of gastric antral perforation caused by the tube tip 12 days after exchange from a PEG tube to a PEG-J tube.

A 49-year-old man with severe dysphagia after brainstem hemorrhage underwent PEG placement using the introducer (direct puncture) technique, and a low-profile button was inserted into the anterior wall of the mid-gastric body. During 1 month of gastric feeding, he developed recurrent nausea and vomiting. Endoscopy showed mild antral torsion without obstruction, and reflux was considered the primary cause. The tube was exchanged for a double-lumen PEG-J tube under endoscopic guidance; however, the jejunal extension could not be advanced beyond the second portion of the duodenum and showed intragastric looping, so the tube was secured with residual intragastric looping and the tip was positioned in the second portion of the duodenum. Enteral feeding was initially tolerated. On day 12, he developed acute right-sided abdominal pain, and CT demonstrated extraluminal migration of the tube tip. Emergency laparotomy revealed perforation of the anterior wall of the greater curvature side of the gastric antrum, just proximal to the pylorus, with localized peritonitis and limited contamination. The perforation was closed primarily and reinforced with an omental patch. To secure a route for enteral nutrition, a gastrojejunostomy with an additional Braun enteroenterostomy was performed. The postoperative course was uneventful, and enteral nutrition was resumed without recurrent reflux symptoms.

Intragastric looping and tube rigidity may cause persistent, focal pressure on the gastric wall and lead to perforation. Careful attention to tube configuration, appropriate device selection, and prompt evaluation of abdominal pain after PEG-J placement are essential.