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Gastro-Hepatic Fistula with Liver Abscess: A Rare Complication of a Common Procedure.

Rafiq A, Abbas N, Tariq H, Nayudu SK - Am J Case Rep (2015)

Bottom Line: It is a safe, cost-effective procedure; however, has its own complications and adverse effects that can be life threatening.However, on further evaluation she was found to have a dislodged PEG tube, which led to development of gastro-hepatic fistula and multiple liver abscesses with liver necrosis.It is the first case that describes liver injury resulting from dislodgement rather than the liver being injured during the procedure of PEG tube placement itself.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA.

ABSTRACT

Background: Percutaneous endoscopic gastrostomy (PEG) is a procedure used most commonly for enteral access for nutrition and continuation of treatment in patients when oral nutrition is not possible. It is a safe, cost-effective procedure; however, has its own complications and adverse effects that can be life threatening.

Case report: Here, we present the case of a 76-year-old woman who was sent to a long-term skilled nursing facility after discharge from a hospital a month before, initially admitted for seizures after a fall and diabetic ketoacidosis. She underwent tracheostomy for prolonged respiratory support on mechanical ventilation and also underwent PEG tube placement. She presented in our Emergency Department (ED) with septic shock and multi-organ failure initially attributed to urinary tract infection and possible Clostridium difficile colitis. However, on further evaluation she was found to have a dislodged PEG tube, which led to development of gastro-hepatic fistula and multiple liver abscesses with liver necrosis. Comfort measures were implemented and she died due to her critical condition.

Conclusions: To the best of our knowledge, this is the first case of a PEG tube, with no post-procedure complications, that dislodged and resulted in formation of a gastro-hepatic fistula and multiple liver abscesses. It is the first case that describes liver injury resulting from dislodgement rather than the liver being injured during the procedure of PEG tube placement itself.

No MeSH data available.


Related in: MedlinePlus

Areas of hypo-attenuation and air collection in liver seen prior to injection of contrast (thin arrows).
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f3-amjcaserep-16-652: Areas of hypo-attenuation and air collection in liver seen prior to injection of contrast (thin arrows).

Mentions: Chest X-ray was unremarkable. Ultrasound of abdomen was compatible with emphysematous cholecystitis. Gall bladder was seen to be under-distended, edematous, and appeared thickened. Echogenic foci within the left hepatic lobe were also seen, suggestive of air in the biliary tree (Figure 1). She was then taken emergently for computed tomography (CT)-guided cholecystostomy and drainage. The CT image did not show any cholecystitis but did reveal PEG tube dislodgement, lying outside the gastric cavity along the left lobe of the liver. Areas of vague left hepatic hypo-attenuation were seen with air bubbles (Figures 2, 3). On injecting contrast via the PEG, contrast leakage/filling was seen in a branching pattern representing multiple left liver abscesses around the dislodged PEG with left liver lobe necrosis (Figures 4, 5). A fistulous tract was seen to be formed between the gastric fundus and left hepatic branching system (Figure 6). Because there were multiple small liver abscesses, percutaneous drainage was not attempted. Attempting to remove the PEG tube could have led to more complications because it appeared to be somewhat deep and possibly adherent to the liver. Her condition was too critical for her to be taken for any emergent surgical procedure. She continued to be on vasopressors, with no response to treatment. Her condition was explained to the family in detail and they opted for comfort measures. The patient died on the same day.


Gastro-Hepatic Fistula with Liver Abscess: A Rare Complication of a Common Procedure.

Rafiq A, Abbas N, Tariq H, Nayudu SK - Am J Case Rep (2015)

Areas of hypo-attenuation and air collection in liver seen prior to injection of contrast (thin arrows).
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4588675&req=5

f3-amjcaserep-16-652: Areas of hypo-attenuation and air collection in liver seen prior to injection of contrast (thin arrows).
Mentions: Chest X-ray was unremarkable. Ultrasound of abdomen was compatible with emphysematous cholecystitis. Gall bladder was seen to be under-distended, edematous, and appeared thickened. Echogenic foci within the left hepatic lobe were also seen, suggestive of air in the biliary tree (Figure 1). She was then taken emergently for computed tomography (CT)-guided cholecystostomy and drainage. The CT image did not show any cholecystitis but did reveal PEG tube dislodgement, lying outside the gastric cavity along the left lobe of the liver. Areas of vague left hepatic hypo-attenuation were seen with air bubbles (Figures 2, 3). On injecting contrast via the PEG, contrast leakage/filling was seen in a branching pattern representing multiple left liver abscesses around the dislodged PEG with left liver lobe necrosis (Figures 4, 5). A fistulous tract was seen to be formed between the gastric fundus and left hepatic branching system (Figure 6). Because there were multiple small liver abscesses, percutaneous drainage was not attempted. Attempting to remove the PEG tube could have led to more complications because it appeared to be somewhat deep and possibly adherent to the liver. Her condition was too critical for her to be taken for any emergent surgical procedure. She continued to be on vasopressors, with no response to treatment. Her condition was explained to the family in detail and they opted for comfort measures. The patient died on the same day.

Bottom Line: It is a safe, cost-effective procedure; however, has its own complications and adverse effects that can be life threatening.However, on further evaluation she was found to have a dislodged PEG tube, which led to development of gastro-hepatic fistula and multiple liver abscesses with liver necrosis.It is the first case that describes liver injury resulting from dislodgement rather than the liver being injured during the procedure of PEG tube placement itself.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Bronx Lebanon Hospital Center, Bronx, NY, USA.

ABSTRACT

Background: Percutaneous endoscopic gastrostomy (PEG) is a procedure used most commonly for enteral access for nutrition and continuation of treatment in patients when oral nutrition is not possible. It is a safe, cost-effective procedure; however, has its own complications and adverse effects that can be life threatening.

Case report: Here, we present the case of a 76-year-old woman who was sent to a long-term skilled nursing facility after discharge from a hospital a month before, initially admitted for seizures after a fall and diabetic ketoacidosis. She underwent tracheostomy for prolonged respiratory support on mechanical ventilation and also underwent PEG tube placement. She presented in our Emergency Department (ED) with septic shock and multi-organ failure initially attributed to urinary tract infection and possible Clostridium difficile colitis. However, on further evaluation she was found to have a dislodged PEG tube, which led to development of gastro-hepatic fistula and multiple liver abscesses with liver necrosis. Comfort measures were implemented and she died due to her critical condition.

Conclusions: To the best of our knowledge, this is the first case of a PEG tube, with no post-procedure complications, that dislodged and resulted in formation of a gastro-hepatic fistula and multiple liver abscesses. It is the first case that describes liver injury resulting from dislodgement rather than the liver being injured during the procedure of PEG tube placement itself.

No MeSH data available.


Related in: MedlinePlus