Percutaneous Gastrostomy Tube Placement: Recognizing When Things Go Wrong

Abstract

Percutaneous radiologic gastrostomy is a commonly performed, minimally invasive procedure for long-term enteral access in patients with a variety of conditions. Compared with other methods, it is less invasive, less costly, and safe, with a high technical success rate. The risk of complications is low, and most require only conservative management. Early, accurate diagnosis of more severe complication is crucial, as these may require prompt intervention. Therefore, radiologists should understand the imaging features, clinical presentation, and management of gastrostomy-related complications. This article will review the indications for long-term enteral access, discuss the available methods, summarize the percutaneous radiologic technique, and highlight the associated complications from gastrostomy placement.

Percutaneous radiologic gastrostomy (PRG) offers the least invasive option for long-term enteral access in patients with a variety of conditions. Compared with other methods of enteral access, it is relatively safe and inexpensive with a high technical success rate. While the risk of complications is low, it is imperative that complications be recognized and appropriately managed. This article will review the indications for long-term enteral access, discuss the available methods, summarize the percutaneous radiologic technique, and highlight the associated complications from gastrostomy placement. Through case-based vignettes, the workup, diagnosis, and management of each complication will be emphasized.

Indications

Long-term enteral feeding is indicated in patients with functional gastrointestinal tracts who are unable to maintain sufficient oral intake to meet their nutritional requirements. It is most often indicated in the setting of acute stroke, head and neck cancers, trauma, and a variety of neuromuscular disorders. It is also indicated in patients requiring frequent decompression. Gastrointestinal feeding is preferred over parental feeding in patients with long-term feeding limitations, as it provides immunological and nutritional benefits.

Contraindications

Absolute contraindications to gastrostomy tube placement include active peritonitis, uncorrectable coagulopathy, bowel ischemia, and colonic interposition between stomach and abdominal wall. ^{1 2 3} Relative contraindications to gastrostomy tube placement include gastric varices, ascites, presence of ventriculoperitoneal shunts or peritoneal dialysis catheters, morbid obesity, and certain anatomic alterations. ^{4 5 6}

Technique for Placement

Cross-sectional imaging is reviewed to evaluate hepatic and enteric anatomy and for the presence of ascites prior to placement. Oral contrast the night before or rectal contrast intraprocedurally may be administered to delineate the colon. A limited ultrasound exam may be performed to mark the liver margin. Perioperative cefazolin is given intravenously to reduce the incidence of peristomal wound infections. ⁷

Intravenous fentanyl and midazolam are administered for sedation. A 5-Fr angled catheter is placed into the stomach if one is not present. Glucagon 1 mg is given intravenously to reduce gastric peristalsis. The stomach is inflated with air, providing a large fluoroscopic target and displacing the colon and small bowel. Local anesthetic is given and T-fasteners are placed under fluoroscopy to temporarily tack the stomach against the anterior wall. Aspiration of air and injected contrast confirms intraluminal placement of T-fasteners. Gastric puncture is performed at the mid-to-distal body equidistant between the lesser and greater curvature with an 18-gauge beveled needle. Using Seldinger technique and sequential dilatation, a 14-Fr pigtail retention catheter is placed with the retention loop in the stomach. Contrast is injected to confirm proper positioning. An anchoring suture is placed and the T-fastener sutures are released. Tube feeds are initiated 24 hours after placement.

Safety Profile and Complications

When compared with other techniques for gastrostomy placement, PRGs are generally considered as safe or are safer. In a meta-analysis comparing the safety of PRG to percutaneous endoscopic gastrostomy (PEG) in head and neck cancer patients, the major complication rates were 7.4 and 8.9%, minor complications rates were 19.5 and 22.1%, and mortality rates were 2.2 and 1.8% for PEG and RIG, respectively. ⁸

PRG has distinct advantages in certain patient populations. In head and neck cancer patients, a small bore catheter can be advanced across an obstructing oropharyngeal/esophageal lesion and into the stomach with greater success than a larger endoscope. Additionally, concerns of tract seeding can be mitigated with PRG. ⁹ In patients with amyotrophic lateral sclerosis or with significant respiratory impairment, PRG is associated with a lower intra- and periprocedural aspiration risk, due to lighter sedation and use of a smaller caliber nasogastric catheter. ¹⁰ Peristomal site infection rates have been found to be lower with PRG compared with PEG, presumably because the gastrostomy tube is not pulled through oral and pharyngeal flora. ^{11 12}

The current guidelines from the Society of Interventional Radiology classifies complications as minor adverse events, moderate adverse events, severe adverse events, life-threatening or disabling adverse events, or events leading to patient death or unexpected pregnancy abortion. ¹³ This system allows for consistency of reporting and potential for incorporation into existing quality-assurance framework ( Tables 1 and 2 ). The remainder of this article will discuss the presentation, workup, diagnosis, and management of these complications using clinical vignettes.

Table 1. Society of Interventional Radiology (SIR) classification of complications.

SIR adverse events severity scale based on escalation of level of care
Mild adverse event	No therapy or nominal (nonsubstantial) therapy (postprocedural imaging performed and fails to show manifestation of AE); near miss (e.g., wrong site of patient prepared, recognized, and corrected before procedure, wrong patient information entered for procedure)
Moderate adverse event	Moderate escalation of care, requiring substantial treatment, e.g., intervention (description of intervention and result of intervention) under conscious sedation, blood product administration, extremely prolonged outpatient observation, or overnight admission after outpatient procedure not typical for the procedure (excludes admission or hospital days unrelated to AE)
Severe adverse event	Marked escalation of care, i.e., hospital admission or prolongation of existing hospital admission for >24 h, hospital admission that is atypical for the procedure, inpatient transfer from regular floor/telemetry to intensive care unit, or complex intervention performed requiring general anesthesia in previously nonintubated patient (generally excludes pediatrics or in circumstances in which general anesthesia would primarily be used in lieu of conscious sedation, e.g., in mentally challenged or severely uncooperative patients)
Life-threatening or disabling event	Life-threatening or disabling event, e.g., cardiopulmonary arrest, shock, organ failure, unanticipated dialysis, paralysis, loss of limb or organ
Patient death or unexpected pregnancy abortion	Patient death or unexpected pregnancy abortion

Abbreviation: AE, adverse event.

Table 2. Potential early and late complications of gastrostomy tubes.

Early complications	Late complications
Abdominal wall abscess or cellulitis	Intraperitoneal leakage of gastric contents
Intraperitoneal leakage of gastric contents	Gastric perforation
Gastric perforation	Transhepatic placement
Epigastric artery pseudoaneurysm	Hepatic abscess
Benign pneumoperitoneum	Aspiration pneumonia
Transhepatic placement	Transcolonic placement
Hepatic abscess	Post pyloric migration with dumping syndrome
Aspiration pneumonia	Malpositioning of the gastrostomy catheter within the abdominal wall
Transcolonic placement	Tube clogging
Tube clogging

Clinical Vignettes

Scenario 1: A 67-year-old woman presents with erythema, pain, and swelling 4 weeks after placement of a PEG. Despite a 10-day course of antibiotics, symptoms progressed with new purulent drainage ( Fig. 1a ).

Fig. 1.

A 67-year-old woman presenting with erythema, pain, and swelling 4 weeks after percutaneous endoscopic gastrostomy tube placement. ( a ) Erythema around the stoma and umbilicus worsened despite 10-day course of antibiotics. ( b ) CT of the abdomen and pelvis demonstrates the gastrostomy catheter to be appropriately positioned with the tip in the stomach (not pictured). There is a large, peripherally enhancing fluid collection within the anterior abdominal wall with extension into the preperitoneal space (white arrowheads). There is also stranding of the subcutaneous and intraperitoneal fat related to inflammation. These findings are consistent with an abdominal wall abscess.

Differential diagnosis : Stomal cellulitis, abdominal wall abscess, and necrotizing fasciitis.

Clinical workup : Determine the patient's immune status. Inquire about systemic symptoms and abdominal pain. Examine the abdomen for signs of peritonitis and the stoma for signs of infection, palpable fluid collections, or crepitus. Inspect the catheter for evidence of migration.

Imaging : Computed tomography (CT) of the abdomen and pelvis with intravenous contrast facilitates an evaluation for abscess formation and involvement of the gastrostomy tract, which necessitates catheter removal and surgical enterotomy repair. High-density peritoneal fluid and peritoneal thickening are seen with leakage of gastric contents and peritonitis. The presence of extensive gas within the subcutaneous tissue and stranding deep to the fascia distant to the gastrostomy site should prompt the diagnosis of necrotizing fasciitis. ^{6 14 15}

Diagnosis : Abdominal wall abscess and cellulitis ( Fig. 1b ).

Management and discussion : Peristomal wound infections are one of the most common complications, reported in up to 45% of patients with varying levels of severity. ¹⁶ Wound infections are most often related to poor wound care, but can also be procedure related. Immunocompromised patients with diabetes, malignancy, or chronic steroid therapy are at an increased risk of infection. ¹⁷ Most gastrostomy-associated infections are cases of limited superficial skin cellulitis and can be managed conservatively with antibiotics.

Superficial and deep abscesses are a more serious complication of percutaneous gastrostomy tubes. This is caused by the introduction of skin flora, which may occur despite adequate skin preparation. Abscesses can also form by introduction of gastric contents or oral flora into the tract. The peristomal infection rate of PRGs is thought to be less than PEG, because the catheter is not pulled through oral and pharyngeal flora. ^{11 12} In addition to antibiotics, treatment includes percutaneous drainage or surgical debridement, and removal of the gastrostomy tube if there is extension of the abscess along the catheter tract.

Necrotizing fasciitis is a rare, but fatal complication which can occur with PEG and PRG, usually associated with immunocompromised states. ^{18 19} Although crepitus is classically reported on physical examination, this is not always appreciated. Treatment includes aggressive surgical debridement, broad-spectrum antibiotics, and intensive supportive care including hyperbaric oxygen.

Scenario 2: Interventional radiology (IR) is consulted for abdominal pain and leakage around the gastrostomy site 5 days after gastrostomy placement and tube feed initiation.

Differential diagnosis, clinical workup, and imaging : Same as the previous case.

Diagnosis : Intraperitoneal leakage of gastric contents and peritonitis ( Fig. 2 ).

Fig. 2.

Patient with diffuse abdominal pain and leakage around gastrostomy tube. ( a, b ) Axial CT images at the time of consultation demonstrates intraperitoneal free air (black arrowheads) with extravasation of oral contrast into the peritoneum (white asterisks). There is fluid centered around the anterior stomach. There is thickening of multiple bowel loops (black arrows). ( c ) Injection of contrast under fluoroscopy demonstrates extravasation into the peritoneum (black arrowheads) through the gastrostomy catheter site.

Management and discussion : Not all leakages around the gastrostomy site are due to infection. Intraperitoneal leakage of gastric contents through the gastrostomy tract is an early complication and can lead to peritonitis. Intraperitoneal leakage may be due to enlargement of the gastrostomy defect and loss of apposition of the stomach to the abdominal wall. Some physicians suggest that repeat microtrauma from pulling on the catheter may also be a cause. ²⁰ Leakage can also develop if the tube is dislodged from the stomach. ²¹

If peritonitis is absent and enteral feeds have not been initiated, conservative management includes antibiotic use and withholding enteral feeds. A gastropexy to support the stomach and promote healing is another option. Consultation with surgeon should always be made in the setting of peritonitis, or if enteral feeds have been initiated. Some interventional radiologists advocate delayed release of T-fasteners to allow for better apposition of the stomach and the abdominal wall.

Scenario 3: A 75-year-old medical intensive care unit patient 5 days postgastrostomy tube placement presents with hypotension, metabolic acidosis, abdominal pain, and erythema around gastrostomy site.

Differential diagnosis : Septic shock, mesenteric ischemia, pancreatitis, peritonitis from leakage of gastric contents.

Clinical workup : Check vital signs for signs of hypovolemia/septic shock. Examine the patient for peritoneal signs. Laboratory tests should include lactic acid and blood cultures.

Imaging : When peritonitis is suspected, CT abdomen and pelvis (CTAP) should be performed to evaluate for peritoneal thickening and enhancement, the presence of fluid collections, free fluid, or pneumoperitoneum.

Diagnosis : Gastric perforation and peritonitis ( Fig. 3 ).

Fig. 3.

A 75-year-old medical intensive care unit patient with signs and symptoms of septic shock 5 days following gastrostomy catheter placement. ( a, b ) CT of the abdomen demonstrates interval development of free intraperitoneal gas (black arrowheads) and a moderate amount of free intraperitoneal fluid (white asterisks), as well as development of subcutaneous gas in the anterior abdominal wall (white arrows). The gastrostomy catheter Cope loop terminates in the stomach. These findings were concerning for gastric perforation with peritonitis. This was later confirmed at the time of surgery.

Management and discussion : Gastric perforation can be an early or late complication of gastrostomy tubes and can present in ways similar to a peristomal wound infection and gastric leakage. Peritonitis is a rare but serious complication resulting from intraperitoneal leakage of gastric contents around an enteral puncture site, gastric wall perforation from catheter migration and erosion of the gastric wall, or enterotomy from gastropexy. CT examination would reveal similar findings to peritonitis from intraperitoneal leakage including free fluid and peritoneal thickening. Consultation with surgeon should occur, as the acute abdomen is a surgical emergency requiring laparotomy and gastric repair. In this case, a large perforation resulting from a T-fastener was found during surgery.

Scenario 4: A 60-year-old man presents to the emergency department (ED) 7 days after gastrostomy tube placement with persistent bleeding around the stoma and abdominal pain.

Differential diagnosis : Rectus sheath hematoma, epigastric artery pseudoaneurysm, and upper gastrointestinal bleed.

Clinical workup : Ask about administration of anticoagulation or antiplatelet therapy. Determine if there is hematemesis or melena. Determine if bleeding is around catheter, suggestive of an extraluminal bleed, or through catheter, suggestive of an intraluminal upper gastrointestinal bleed. Palpate the abdomen for abdominal wall mass or hematoma. Assess the patient's hemodynamic status. Laboratory evaluation should include coagulation studies and complete blood count.

Imaging : When an arterial source of bleeding is suspected, particularly in the setting of hemodynamic instability, a CT angiography should be the first imaging study to evaluate the source of bleeding. This should include precontrast, arterial, and venous phases. The results of these studies will guide any subsequent conventional angiography for treatment with embolization of the culprit artery. While less sensitive, ultrasound can be used to evaluate for epigastric artery pseudoaneurysm in patients unable to receive intravenous contrast.

Diagnosis : Epigastric artery pseudoaneurysm ( Fig. 4 ).

Fig. 4.

A 60-year-old male presents to the emergency room 7 days after gastrostomy catheter placement with persistent bleeding around the stoma and abdominal pain. ( a ) CT of the abdomen and pelvis demonstrates a gastrostomy tube in the appropriate location within the lumen of the stomach. There is an adjacent rectus sheath hematoma (white asterisk). ( b ) Selective arteriography of the left superior epigastric artery demonstrates a small pseudoaneurysm (black arrow) arising adjacent to the gastrostomy catheter.

Management and discussion : Inadvertent vascular injury occurs in approximately 1.4 to 2.5% of gastrostomy tube placements. ^{1 22} Iatrogenic injury of the superior epigastric artery during gastrostomy tube placement is rare. This artery courses the junction of the medial two-thirds and lateral one-third of the rectus. Iatrogenic pseudoaneurysm of this vessel has a similar presentation to rectus sheath hematoma. ²³ Characteristic to-and-fro ultrasound pattern can help differentiate this from a simple hematoma. ²⁴ Coagulation factors should be corrected. Treatment is coil embolization. ²⁵ Direct injection of pseudoaneurysm with thrombin under ultrasound guidance is an acceptable alternative. ²⁶

Iatrogenic injury of intrinsic gastric arteries is also rarely encountered with PRG catheter placement. The gastroepiploic arteries supply the greater curvature of the stomach, while the left and right gastric arteries supply the lesser curvature of the stomach. Gastric puncture should be equidistant from the lesser and greater curvatures to reduce iatrogenic injury to these vessels. ^{27 28}

Scenario 5: A 63-year-old patient presented to the ED with left lower quadrant pain 7 days after placement of a gastrostomy tube. Initial chest radiograph showed large volume pneumoperitoneum.

Differential diagnosis : Gastric or bowel perforation and benign pneumoperitoneum.

Clinical workup : Examination of the patient's abdomen for peritoneal signs should be performed on patient with pneumoperitoneum. Ask about abdominal pain and fevers.

Imaging : CT imaging should be performed in patient with pneumoperitoneum and symptoms concerning for perforation. Even in the absence of symptoms, CT may also be indicated in patients with moderate to large volume of pneumoperitoneum. Additional findings of a perforated viscous include free fluid, localized peritoneal fat stranding, focal bowel wall thickening, or focal bowel wall discontinuity.

Diagnosis : Small gastric perforation with mild leakage of gastric contents into the peritoneal cavity ( Fig. 5 ).

Fig. 5.

A 63-year-old head and neck cancer patient presented to the emergency department with left lower quadrant pain 7 days after placement of a gastrostomy catheter. IR consulted after pneumoperitoneum seen on chest radiograph. ( a ) Initial chest radiograph showed large volume pneumoperitoneum (white asterisks). ( b ) CT of the abdomen was subsequently obtained, which redemonstrated pneumoperitoneum (white asterisk) but did not show any additional signs of hollow viscus perforation. There was, however, a site of relatively focally thinned gastric wall just superior to the gastrostomy tube insertion site.

Management and discussion : Due to the persistent abdominal pain and indeterminate CT findings, the patient was taken to the operating room for a diagnostic laparoscopy and found to have a small perforation allowing leakage of gastric contents into the peritoneal cavity. Because the perforation was small and there was no gross evidence of peritonitis, the stomach was oversewn, leaving the gastrostomy tube in place. A gastropexy was also performed to help adherence of the stomach to the abdominal wall. This case demonstrates that larger than expected volume of pneumoperitoneum in a symptomatic patient necessitates further workup.

Scenario 6 (companion case ): IR is consulted for pneumoperitoneum seen on a chest radiograph in a 60-year-old man presenting to the ED for shortness of breath.

Differential diagnosis, clinical workup, and imaging : same as previous case.

Diagnosis : Benign expected pneumoperitoneum.

Management and discussion : Small volume pneumoperitoneum can be incidentally encountered on chest radiographs of patients of recent gastrostomy tube placement. The incidence of pneumoperitoneum after PRG is not well reported; however, the incidence of pneumoperitoneum with PEG is 4.7 to 55.6% of placements. ²⁹ Inflated air from the stomach may escape into the peritoneal cavity during gastrostomy tract creation and has a self-limited course.

Controversy exists regarding how much pneumoperitoneum is considered benign and how long benign pneumoperitoneum can persist after catheter placement. Some physicians have suggested that even without peritoneal signs and symptoms, iatrogenic bowel injury may be present and all pneumoperitoneum requires further diagnostic studies. ³⁰ This is particularly true of ICU patients and those with altered mental status where the usual clinical symptoms of peritonitis can be masked. ³¹ If signs of peritonitis or infection are present, further evaluation is necessary. Moderate or large pneumoperitoneum after gastrostomy tube placement, even without peritoneal signs, should still arouse suspicion of complicated pneumoperitoneum due to iatrogenic bowel injury.

Scenario 7: An ED physician calls with an asymptomatic patient in the emergency room with an incidental finding of intrahepatic gastrostomy tube placement on CT.

Differential diagnosis : Intrahepatic/transhepatic gastrostomy tube placement, associated complications including hepatic abscess or intrahepatic hemorrhage.

Clinical workup : In patients with right upper quadrant (RUQ) pain, considerations should include liver, gallbladder, or pancreatic pathology. The presence of fever and jaundice should be determined. Evaluate for signs of peritonitis. Nonepigastric causes of RUQ pain including cardiac pain, PE, and pneumonia should be excluded.

Imaging : CT imaging with multiplanar reformats is the best imaging of choice to confirm the course and positioning of the gastrostomy tube. In the asymptomatic patient with the incidental finding of a transhepatic gastrostomy tube, no further imaging is needed. CT with contrast or ultrasound can be obtained for evaluation of complications such as abscess or hematoma.

Diagnosis : Transhepatic placement of gastrostomy tube through the left lobe of the liver ( Fig. 6 ).

Fig. 6.

( a ). Transverse contrast-enhanced CT image shows the gastrostomy tube traversing the lateral left liver (white arrow). The administered contrast is within the stomach and there is normal positioning of the cope loop within the stomach (white arrowhead). ( b ) Coronal reformatted image also confirms that the gastrostomy tube traverses the liver (white arrow).

Management and discussion : Injury to the liver can occur with both PRG and PEG catheters. The presentation of patients with transhepatic placement can vary. Diagnosis of asymptomatic patients with accidental transhepatic PEG placement needs a high index of suspicion and can be very challenging. In this case, the patient was asymptomatic, and fluoroscopic interrogation of the catheter demonstrated the cope loop within the fundus, and no leakage of contents around gastrostomy tube within the liver. Leakage should be evaluated in the symptomatic patient, as this can predispose the patient to intraperitoneal or hepatic abscesses. Symptoms may be limited to pain related to deep breathing and movement due to motion of the catheter with respect to the liver and is usually relived with analgesics.

There are no standard treatment recommendations for patients found to have incidental transhepatic placement of gastrostomy tubes. There are several case reports in the literature of patients with incidental transhepatic catheters doing well without development of subsequent problems. Based on the limited data available, it should be reasonable to leave the tube in place if patients are asymptomatic and tolerating tube feeds. ^{32 33} In symptomatic patients, it is prudent to stop tube feeds and to replace the tube once a mature tract has formed to prevent worse complications.

Scenario 8 (companion case): An ED resident calls about a patient with RUQ pain, fevers, leukocytosis, and elevated liver enzymes.

Differential diagnosis, clinical workup, and imaging : same as previous case.

Diagnosis : Hepatic abscess and peritonitis after intrahepatic gastrostomy tube placement ( Fig. 7 ).

Fig. 7.

( a, b ) CT demonstrates the gastrostomy tube terminus outside the stomach and within the liver (white arrow). There is a large hypoattenuating fluid and gas containing collection involves segments II, III, IVa, and IVb (black arrowheads), consistent with an intrahepatic abscess. Intraperitoneal fluid and free air are also noted (white asterisks). There is hyperenhancement of the peritoneum, consistent with peritonitis.

Management and discussion : Pyogenic liver abscesses are rare, but life-threatening complications, and can develop after inadvertent transhepatic transgression during PRG placement. ^{34 35} Ultrasound prior to the procedure to confirm position of the inferior liver edge is a potential way to avoid transhepatic placement of gastrostomy tubes. ³² Massive hepatosplenomegaly may be a relative contraindication to PRG if a safe window of access is not attainable.

Hepatic abscesses can be a result of administration of feeds directly into the liver parenchyma or due to superinfection of a prior hepatic hematoma. Treatment of hepatic abscesses depends on size and complexity of lesion. Antibiotics for smaller (<3 cm) uniloculated lesions may be effective, while percutaneous aspiration or drainage is the mainstay treatment for larger abscesses. ³⁶ Surgery is limited to those patients in whom percutaneous drainage is not feasible or has proven ineffective. ³⁷ Despite treatment, hepatic abscesses have high mortality rates. ³⁸

Scenario 9: An 81-year-old woman presents with feculent leakage around gastrostomy tube.

Differential diagnosis : Transcolonic placement of gastrostomy tube, gastrocolocutaneous fistula.

Clinical workup : Ask about weight loss, diarrhea, melena, feculent discharge around gastrostomy tube, feculent vomiting. Ask about prior abdominal or gastrointestinal surgery. Examine for signs of infection, peritonitis, and feculent drainage.

Imaging : CT of the abdomen, injection of the catheter under fluoroscopy, and barium enemas are all appropriate imaging methods to evaluate cases of suspected transcolonic gastrostomy tube placement. These studies can show the catheter to be within the lumen of the colon or traversing the colon into the stomach.

Diagnosis : Redundant colon superimposed on the stomach with transcolonic placement of the gastrostomy tube ( Fig. 8 ).

Fig. 8.

( a ) CT of the abdomen showing the gastrostomy balloon within the stomach but traversing the transverse colon (white asterisks). ( b ) Intraprocedural colonoscopy photograph confirming the gastrostomy catheter traversing the colon.

Discussion and management : This entity is a rare complication of PRG, but often goes unrecognized until catheter exchange results in intracolonic placement of the new catheter. ³⁹ Insufflation of the stomach usually displaces the colon inferiorly allowing safe access. In some patients, particularly those with prior abdominal surgery, the colon will remain interposed. Strategies to avoid transcolonic placement include use of oral contrast and rectal contrast administration prior to the procedure. The main risk of transcolonic catheter insertion is early colonic leakage and peritonitis, which is life threatening and warrants surgical consult. Many patients, however, remain asymptomatic and this is discovered incidentally or at the time of catheter exchange. In the asymptomatic patient, conservative management is the best initial option because it is very likely that a mature track has formed precluding the risk of peritonitis. The tube should be downsized and removed entirely after a mature track has formed between the colon and skin. ⁴⁰

Scenario 10: Patient presents to the clinic 5 weeks after gastrostomy tube placement with 2 weeks of diarrhea.

Differential diagnosis : Post-pyloric migration of gastrostomy tube, infectious gastroenteritis, and clostridium difficile infection.

Clinical workup : It is important to characterize the diarrhea as being bloody or watery, with timing with respect to tube feeds, and inquire about other systemic symptoms, abdominal pain, recent hospitalization, and/or antibiotic use.

Imaging : Fluoroscopic exam or plain film should be used to evaluate positioning of gastrostomy tube.

Diagnosis : Migration of gastrostomy tube into the duodenum with dumping syndrome ( Fig. 9 ).

Fig. 9.

( a ) Fluoroscopic scout image on follow-up gastrostomy tube evaluation demonstrates interval migration of the catheter from the fundus into the duodenal bulb. ( b ) The catheter was repositioned such that the Cope was within the body of the stomach. Contrast was injected to confirm the catheter cope position.

Discussion and management : Failure of the gastrostomy tube retention device can result in migration into the duodenum. This can lead to dumping syndrome which is characterized by postprandial nausea, vomiting, diarrhea, flushing, and lightheadedness. Migration of the catheter can also result in a proximal small bowel obstruction. Of note, case reports demonstrate migration of PEG tubes resulting in acute pancreatitis due to obstruction/irritation of the ampulla by the balloon. ⁴¹ Directing the initial puncture toward the fundus, securing the tube with a well-formed anchor suture, and ensuring that the external bumper is snug against the abdominal wall can reduce the risk of catheter migration.

Scenario 11: A patient's family calls the IR clinic and complains of gastrostomy tube malfunction and erythema around the catheter insertion site.

Differential diagnosis : Tube clogging, tube migration, peristomal infection, buried bumper syndrome.

Clinical workup : Ask about medication administration and catheter flushing. Inquire about fevers, chills, abdominal pain, nausea, and vomiting. Evaluate catheter positioning and retention suture/device. Examine abdomen for signs of infection and peritonitis.

Imaging : Evaluate the catheter under fluoroscopic guidance if there is malfunction. CTAP should be obtained if there is concern for abscess or peritonitis.

Diagnosis : Malpositioning of the gastrostomy tube within the abdominal wall ( Fig. 10 ).

Fig. 10.

( a, b ) Percutaneous endoscopically placed gastrostomy tube inappropriately placed within the abdominal wall (white arrows), with subsequent development of extensive subcutaneous gas (white asterisks).

Discussion and management : Migration of the catheter is often a result of failed retention device. This is most common with balloon-retained catheters and least common with solid bumpers of PEG tubes. If a gastrostomy tube is dislodged, replacement should be attempted within 24 to 48 hours to avoid closure of the tract. If the tract is mature, a new gastrostomy tube or Foley catheter can be placed in the emergency room or at bedside to prevent tract closure. Intraluminal positioning can be confirmed with injection with contrast and abdominal radiography. If bedside placement is unsuccessful, the catheter should be evaluated under fluoroscopy using an angled catheter and Glidewire to regain access. A de novo gastrostomy catheter is often required in healed tracts.

Buried bumper syndrome is a complication which occurs late after gastrostomy catheter insertion and is most often associated with endoscopically placed catheters. This results from erosion of the internal bumper through the gastric mucosa and into the abdominal wall. It can present as gastrostomy catheter dysfunction, gastric perforation, bleeding, or peritonitis. ⁴² The mechanism is usually excessive traction on the internal bumper. ⁴³ Soft or collapsible internal bumpers allow for nonsurgical removal via external traction. A disc retained inside the stomach and completely covered by the overgrowing tissue can be released using endoscopic dissection techniques. A disc localized out of the stomach or those who have failed endoscopic release require surgical intervention. ^{43 44}

Conclusion

Percutaneous radiologic gastrostomy is a commonly performed, minimally invasive procedure for long-term enteral access in patients with a variety of conditions. The risk of complications is low and most require only conservative therapies. Early, accurate diagnosis of more severe complication is crucial, as these may require prompt intervention by the surgery or interventional radiology team. Therefore, radiologists should understand the imaging features, clinical presentation, and management of gastrostomy-related complications.