A 68-year-old woman with an AbbVie J intestinal tube (AbbVie Inc, North Chicago, Ill, USA) (9F) for percutaneous endoscopic gastrostomy (PEG) kit (15F) percutaneous endoscopic gastrojejunostomy (PEGJ) tube placed 22 months earlier for infusion of Duopa (AbbVie Inc) (a gel medication for Parkinson’s disease) presented because of intermittent abdominal pain and nausea for the previous 4 weeks. On the day of the procedure, the patient additionally stated that the external portion of the tube was being retracted into her abdomen.Upper endoscopy showed that the internal bumper of the PEG part of the PEGJ had migrated into the pylorus. With retraction of the external portion of the PEG tube, the internal bumper was able to be pulled back into the stomach, but retraction was stopped shortly thereafter because of excessive resistance. The endoscope was advanced into the small bowel to identify the source of resistance, and evidence was found of an intussusception in the distal duodenum preventing removal of the jejunal extension tube (Fig. 1).
Figure 1
Small-bowel intussusception from attempted removal of jejunal extension tube.
Small-bowel intussusception from attempted removal of jejunal extension tube.The internal bumper of the PEG portion of the PEGJ tube was passed into the small bowel by pushing on the external portions of the PEG. The presence of the PEG in the small bowel stabilized the small bowel and provided additional countertraction. Finally, the jejunal extension tube could be pulled and withdrawn through the PEG tube. The intussusception remained until a bezoar that had formed on the distal pigtail portion of the jejunal extension tube was pulled into the proximal duodenum. The bezoar/pigtail portion of the jejunal tube was then pulled into the stomach (Fig. 2). The jejunal extension tube was cut externally, and the bezoar was removed with a net (Fig. 3). The PEG was then cut externally, and the internal bumper was removed with a snare by use of an overtube. Finally, a PEGJ replacement was accomplished without further adverse events (Video 1, available online at www.VideoGIE.org).
Figure 2
Bezoar that had formed on the distal end of the jejunal extension tube retracted into the stomach.
Figure 3
Bezoar on distal pigtail end of jejunal extension tube after endoscopic removal.
Bezoar that had formed on the distal end of the jejunal extension tube retracted into the stomach.Bezoar on distal pigtail end of jejunal extension tube after endoscopic removal.It is likely that the bezoar that had formed on the distal pigtail portion of the jejunal extension tube of the PEGJ had caused an intermittent partial obstruction for the previous 4 weeks. The patient’s additional symptoms the day of the procedure were caused by distal migration of the PEG tube internal bumper, likely precipitated by intestinal peristalsis on the bezoar, promoting distal migration of the entire PEGJ.
Disclosure
All authors disclosed no financial relationships relevant to this publication.
Figure 1
Figure 2
Figure 3