Balloon gastrostomy migration leading to acute pancreatitis

A 57 year old woman with cerebrovascular disease had a 16 Fr Corflo percutaneous endoscopic gastrostomy (Merck Gastroenterology, West Drayton, Middlesex, UK) exchanged for a 20 Fr replacement Corflo balloon gastrostomy (volume 5 ml) as a bridge to eventual insertion of a permanent 20 Fr Corflo‐cuBBy “button” gastrostomy. Four weeks later she presented with a seven day history of abdominal pain and vomiting. Initial investigations revealed a serum alanine transaminase level of 54 IU/l (normal range (NR) 0–35), serum alkaline phosphatase level of 491 IU/l (NR 70–300), serum bilirubin level of 7 μmol/l (NR 5–21), and serum amylase level of 703 IU/l (NR <110). An abdominal ultrasound examination demonstrated a dilated common bile duct but no stones were seen in the gallbladder. A subsequent magnetic resonance (MR) cholangiopancreatogram revealed the gastrostomy tube traversing the stomach into the duodenum (fig 1), with the inflated balloon in the second part of the duodenum (figs 2, 3). No filling defects were visible in the biliary tree (fig 3). Forward viewing gastroscopy confirmed the location of the gastrostomy balloon in the duodenum. This was deflated and repositioned in the stomach. Side viewing duodenoscopy confirmed a small erythematous papilla adjacent to the site of the gastrostomy balloon. A diagnosis of acute pancreatitis secondary to obstruction by the gastrostomy balloon was made. Therefore, an endoscopic retrograde cholangiopancreatogram was not performed. Her symptoms settled promptly and blood investigations all returned to normal over a period of six days.

Figure 1 True FISP (fast imaging with steady state precession) magnetic resonance transaxial slice, showing the gastrostomy tube (arrowhead) traversing the stomach into the duodenum.

Figure 2 True FISP (fast imaging with steady state precession) magnetic resonance transaxial slice, demonstrating the inflated balloon (arrowhead) lying in the second part of the duodenum.

Figure 3 Thick slab, single shot, fast spin echo sequence, demonstrating a dilated biliary tree. There were no calculi in the gallbladder or bile ducts. The gastrostomy balloon is visible at the bottom of the image.

This is the sixth reported case of acute pancreatitis or obstructive jaundice secondary to gastrostomy balloon migration.¹ However, this is the first description to include visualisation of the gastrostomy balloon in situ by MR imaging. We currently advise patients to rotate the replacement gastrostomy tube intermittently in order to maintain tract patency prior to “button” gastrostomy insertion. In our case, we believe that this instruction led to inadvertent distal migration of the gastrostomy balloon, despite the presence of a moveable external anchor device. In the light of this case, we now counsel patients/carers about this rare potential outcome and ensure that a visible reference mark on the external portion of the tube is recognised by the patient/carer in order to maintain an appropriate balloon position in the stomach.