Severe recurrent gastrointestinal bleeding following percutaneous endoscopic gastrostomy tube placement: a rare complication

Abstract

Severe bleeding requiring blood transfusions following endoscopic, percutaneous gastrostomy tube placement is a rare complication. We describe a case of severe recurrent haemorrhage with bright red blood from rectum from endoscopic, percutaneous gastrostomy tube placement, which ultimately required removal of the percutaneous endoscopic gastrostomy tube.

Background

Percutaneous endoscopic gastrostomy (PEG) tube is placed in patients who require long-term enteral nutrition, therapeutic or palliative stomach decompression when clinically indicated.¹ A frequently performed procedure, complications may include tube site pain, infection, minor bleeding and perforation or injury to nearby structures.¹ Significant recurrent bleeding requiring repeated blood transfusion following PEG tube placement is an infrequent complication. We report a case of symptomatic and recurrent haemorrhage following PEG tube placement, which ultimately required removal of the PEG tube.

Case presentation

A 94-year-old man was admitted to the hospital for recurrent aspiration pneumonia and dysphagia. His medical history was notable for laryngeal cancer status post radiation therapy and paroxysmal atrial fibrillation on Apixaban. A decision was made to place a PEG tube for management of dysphagia and prevention of further episodes of recurrent aspiration. Apixaban was held for 48 hours prior to theendoscopic procedure. The PEG tube site was identified by transillumination, one-to-one apposition on palpation and under direct vision. Then a 20 Fr gastrostomy tube was placed endoscopically by the pull-through method. Forty-eight hours after the procedure, a moderate amount of blood was noticed around the PEG tube insertion site while feeding. The patient subsequently experienced a syncopal episode while having a large bowel movement which contained bright red blood in it. On examination, there was a medium amount of blood on PEG dressing, however, there was no clinical evidence of an active bleeding or haematoma. There was bright red blood in the PEG tube on multiple aspirates. About 50 mL of blood in total was aspirated. There was also a significant drop in haemoglobin from 9.1 to 7.2 g/dL. Following transfusion, esophagogastroduodenoscopy (EGD) was performed which showed clots around the PEG tube insertion site (figure 1). Blood clots were then removed, and there was no sign of active bleeding. Gold probe coagulation and 4 cm³ of 1:10 000 dilution epinephrine injection were applied locally. The patient remained stable for the rest of his hospitalisation with no evidence of further bleeding at the PEG tube insertion site. Haemoglobin remained stable at 9.8 g/dL. He was discharged with instructions to resume his oral anticoagulants 3–4 days later. However, the patient was readmitted 5 days later with complaints of intermittent external bleeding around the PEG tube site after gravity feeding. It was associated with the passage of a large amount of bright red blood per rectum (BRBPR) and near syncope. The patient was admitted to passing melena-coloured stools followed by dark red blood prior to noticing BRBPR. Abdominal examination was unremarkable and at that time there was no evidence of active bleeding at the PEG tube insertion site. His haemoglobin was 8.6 g/dL at presentation, and the clotting profile was unremarkable: prothrombin time (PT), 10.7 s; activated partial thromboplastin time (aPTT), 28.1 s and international normalised ratio (INR), 1.0. Twenty-four hours after admission, a moderate amount of blood was noticed on the PEG dressing and the patient had another episode of BRBPR. His haemoglobin had dropped to 6.9 g/dL. He was given 2 units of blood. Diagnostic EGD which was performed the next day did not show any sign of active bleeding at the PEG tube insertion site (figure 2). The patient continued to have intermittent large amounts of BRBPR (total of three episodes) during his hospitalisation. CT of the abdomen and pelvis with contrast was unremarkable (figure 3). A tagged red blood cell (RBC) scan was negative for acute bleeding (figure 4). He was given a total of 7 units of blood during this hospitalisation. On day 3, the passages of BRBPR resolved, and the patient’s haemoglobin remained stable at 8.4 g/dL for 48 hours. He was discharged with instructions not to resume Apixaban and to repeat haemoglobin in 48 hours. Forty-eight hours after discharge, the patient again presented to the hospital and was readmitted with near syncope and passage of BRBPR. Prior to the onset of symptoms, he reported the passage of melena-coloured stools which gradually progressed to dark and red blood. He also reported noticing bleeding at the PEG tube insertion site. At presentation, vital signs were unremarkable. Abdominal examination revealed dried blood on the abdomen and around the PEG tube insertion site; however, there was no active bleeding. His haemoglobin at presentation was 5.1 g/dL (he had his haemoglobin checked earlier in the day at his primary care physician’s office before the presentation, which was 9.1 g/dL). The patient’s creatinine was 1.34 mg/dL (baseline 1.3 mg/dL). Clotting profile was unremarkable (PT, 10.0 s; INR, 1.1; apTT, 28.9 s). He was transfused with 2 units of blood following which his haemoglobin improved to 7.0 g/dL.

Figure 1.

Esophagogastroduodenoscopy showing blood clot around percutaneous gastrostomy tube insertion site pre-treatment and post-treatment with epinephrine and gold probe photocoagulation.

Figure 2.

Esophagogastroduodenoscopy performed during the second hospitalisation showing no signs of bleeding at the percutaneous endoscopic gastrostomy tube insertion site.

Figure 3.

CT of abdomen and pelvis with contrast showing normal percutaneous gastrostomy tube insertion without perforation or adjacent organs.

Figure 4.

Technetium-99m-labelled red blood cell scans which were negative for active bleeding. RBC, red blood cell.

Treatment

A multidisciplinary team meeting between the primary, surgery and gastroenterology teams was held. The options were discussed after which a decision to remove the PEG tube endoscopically was made with the closure of the tract externally by surgery since the bleeding was felt to be from a vessel in the subcutaneous tissue and not from gastric mucosa. The gastrostomy tube was removed endoscopically and pulled through the mouth and sutures were placed by the surgical team to close PEG tract externally. A small amount of bleeding was noted at the site internally. Four endo clips were placed at the site internally with the achievement of good hemostasis (figure 5).

Figure 5.

Post percutaneous gastrostomy tube removal with the placement of endo clips to achieve hemostasis.

Outcome and follow-up

The patient’ s haemoglobin subsequently remained stable with no more evidence of BRBPR. Three days later, another PEG tube was placed since he had dysphagia, and, therefore, needed a permanent source of nutrition. He tolerated the procedure without any post-procedural complications. He followed up with his primary care physician in 72 hours and 2 weeks. The patient’s haemoglobin was stable and he did not have melena or BRBPR.

Discussion

Bleeding can complicate gastrostomy tube placement; however, severe bleeding is an uncommon adverse phenomenon. A prior literature review does not show any difference in its incidence when placed by either surgery, interventional radiology or gastroenterology.¹ Its overall morbidity and mortality are lower in patients undergoing PEG compared with other methods of gastrostomy tube placement.^{2 3} Bleeding secondary to PEG placement can likely occur due to injury to the anterior abdominal wall and adjacent vessels, liver, oesophagitis, gastritis, ulceration or traumatic erosions of the gastric mucosa.^{1 4} Post-procedural severe bleeding with haemodynamic instability is rare with endoscopic PEG tube placement.

When evaluating patients with gastrointestinal bleed following PEG tube placement, a detailed history and physical examination should be obtained.⁵ A comprehensive history which includes details at the site of bleeding, bleeding in the past and the timing of onset of symptoms may help differentiate procedural complication from non-procedural complication.⁶ Physical examination may reveal oozing of blood at PEG tube site or may reveal peritoneal signs which may be representative of a more severe complication such as intraperitoneal bleeding from a transhepatic placement of the PEG tube.⁵ Bleeding disorder labs such as PT, aPTT and INR should be performed as well. Oesophageal tear as a complication of endoscopy can present similarly, so it needs to be ruled out as well.⁷ In cases where the source of bleeding is not apparent, advanced imaging such as CT scans utilising contrasts, tagged RBC scans, colonoscopy and repeat EGD may be needed to establish a diagnosis and to exclude other possible aetiologies presenting with signs of upper or lower gastrointestinal bleeding independent of the PEG procedure. In the case reported, colonoscopy was not performed because the patient had melena which progressed to more liquid stools containing bright red blood.

In this case, the best explanation for recurrent bleeding is likely injury to an anterior abdominal wall vessel or gastric vessel due to the procedure. Intermittent bleeding may have been due to the dislodgement of clots and re-exposure of the bleeding vessel from trauma associated with the movement of the tube during feeding. In the case reported, the patient did not have any evidence of coagulopathy and was off anticoagulation for the adequate amount of time prior to the procedure. It unknown if the resumption of Apixaban after 48 hours contributed to the increased risk of recurrent bleeding; however, anticoagulation has not been suggested to increase the risk of bleeding in patients undergoing PEG placement if held for the recommended amount of time before the procedure.⁸ More studies are needed to better understand the risk of recurrent bleeding in patients undergoing PEG tube placement and the risk factors associated with bleeding.

To our knowledge, this is the first report describing a patient with significant occult bleeding from the gastrointestinal tract with melena and occasional haematochezia and symptomatic anaemia requiring several blood transfusions following PEG tube placement. This may represent underreporting of this condition or a genuinely rare occurrence.

Learning points.

• Percutaneous endoscopic gastrostomy (PEG) tube placement can be complicated by severe local bleeding.

• Bleeding secondary to PEG tube placement can present in several ways such as bright red blood per rectum or syncope. In such cases, further investigation should be performed with an esophagogastroduodenoscopy regardless of the haemoglobin level.

• In cases of recurrent bleeding at the PEG tube insertion site, the PEG tube needs to be removed to prevent further episodes. Afterwards, it could be inserted from a different area of the stomach.