AHRQ WebM&M: Morbidity & Mortality Rounds on the Web
August 2012
Wrong Turn through Colon: Misplaced PEG
Commentary by Rachel Sorokin, MD, and Mitchell Conn, MD, MBA
The Case | |
An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a past cerebrovascular accident (CVA) with resulting dysphagia required placement of a feeding tube. The feeding tube was a percutaneously placed gastric tube, placed by gastroenterology 1 month before admission.
During hospitalization, the patient tolerated his tube feeds until hospital day 4, when he developed loose stools. The diarrhea progressed with liters of watery stool daily, necessitating placement of a rectal tube. Various stool studies were sent and failed to reveal an etiology. Bulking agents were added to his tube feeds but did not improve the consistency or volume of his stools. The primary team noted a remarkable similarity in appearance between the tube feeds and the stool. During a tube check, it was discovered that the tip of the feeding tube was in the colon and not the stomach.
On further investigation, it was determined that a loop of colon was overlying the stomach when the tube was placed. Consequently, while entering the stomach, the gastroenterologists inadvertently passed through the colon. Over time, a fistula formed between the stomach and the adjacent bowel (through which the tube passed during insertion); ultimately, the tube migrated back into the colon, which meant that the feedings were bypassing the entire digestive apparatus of the small intestine.
After the error was recognized, another tube was placed in the stomach and the previously placed tube was removed. However, the delay in identifying the problem resulted in sustained inadequate nutrition and significant decompensation.
AHRQ WebM&M: Morbidity & Mortality Rounds on the Web
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