Gastrostomy or gastrojejunostomy feedings for provision of adequate nutrition frequently are necessary in many neurologically impaired children because safe delivery of oral nutrition is often compromised in such patients. It also is used in other situations without neurologic impairment, when prolonged use of enteral supplements is necessary. Although these feeding routes are tolerated safely, there can be significant morbidity and even mortality associated with the use of feeding tubes. Increased awareness of these potential complications may help to improve management. We present a case in which obstruction of the duodenal bulb by migration of the gastrojejunostomy balloon was not recognized initially, leading to multiple other major surgical interventions.
A 17-year-old white boy with spastic cerebral palsy, seizure disorder, and developmental delay secondary to prematurity complicated by severe perinatal asphyxia presented with emesis for 3–4 days before admission. A ventriculoperitoneal shunt (VPS) had been inserted at 6 weeks of age for hydrocephalus, which needed frequent revisions. A gastrostomy tube was inserted at 5 years of age for swallowing incoordination. This was converted subsequently to a gastrojejunal tube radiologically, through which the patient received enteral formula by continuous infusion. The patient also had chronic gastroesophageal reflux disease and was treated with ranitidine and cisapride.
Six months after the last VPS revision, the patient had intermittent vomiting for 3–4 days. He was admitted and underwent VPS revision for presumed shunt malfunction (day 1). Within 48 hours of this intervention, vomiting recurred even while the patient was still fasting. Although an emergent computed tomography scan of the head showed a decompressed ventricular system, injection of the shunt tubing did not show any fluid movement, so the VPS was revised again on the third day. Immediately after the second revision, the patient had persistent emesis, which was presumed to be secondary to general anesthesia. The emesis persisted on day 5, and a shunt reservoir tap showed no proximal flow and a collapsed reservoir. He was taken again to the operating room for a third VPS revision. A nasogastric tube inserted in the operating room after shunt revision revealed coffee-ground contents. The gastroenterology service was consulted immediately.
Emergent esophagogastroduodenoscopy using an Olympus GIF 100 endoscope (Olympus America Inc., Melville, NY, U.S.A.) showed moderate to severe circumferential erythema involving the distal esophagus with erosions and some mucosal hemorrhage with an indwelling nasogastric tube in place. The nasogastric tube had been left in situ by the anesthesiologist, when they noticed coffee-ground material during routine postoperative gastric aspiration. On entering the stomach, foreshortening of the gastrojejunal tube was noted from the anterior wall of the stomach with the gastric balloon missing in the gastric lumen. The gastrojejunal tube was noted to traverse through the pylorus, which was bulging (Fig. 1). The gastrojejunal tube could not be retracted by pulling from the external aspect. It appeared that the gastric balloon had migrated through the pylorus, causing mechanical obstruction of the gastric outlet. Upon deflation of the gastric balloon, it was possible to withdraw the balloon back into the stomach to its proper position and reinflate it. Later, the marking up to which the tube should be seen externally from the skin was shown and explained to the mother to prevent such migration in future. The patient did well after endoscopy while receiving intravenous ranitidine and metoclopramide and tolerated gradual reintroduction of enteral feeds. He subsequently underwent a fundoplication because the parents did not want ongoing gastrojejunal tube feedings.
This patient had multisystem problems associated with cerebral palsy, including hydrocephalus, for which he had a preexisting VPS that was revised multiple times. He presented with persistent vomiting, which eventually resulted in coffee-groundlike aspirates. His symptoms were believed to be secondary to increased intracranial pressure. However, he did not respond to three shunt revisions performed during a 5-day period. Decompression of the retention balloon and repositioning in the appropriate place beneath the anterior stomach wall led to resolution of the symptoms in the patient. Early recognition of this problem may have prevented additional surgeries. A clue in the parental history, which may have helped pinpoint the source of the problem, was that the mother had noticed a change in the marking on the gastrostomy tube exiting the abdominal wall. However, it was not registered as a significant problem.
Although percutaneous endoscopic gastrostomy frequently is performed in pediatric patients for enteral feedings, it should be considered to be a major undertaking (1). Risks and complications include those secondary to anesthesia or sedation and those resulting from the procedure itself. Minor complications reported were leakage, skin infection, granulation tissue, recurrent chest infections, local pain, difficulty tolerating feeds, and stoma irritation (1,2). Major complications included the new development of or exacerbation of gastroesophageal reflux needing antireflux procedures, intestinal obstruction, gastrocolic fistula, duodenal hematoma, complicated pneumoperitoneum, necrotizing fasciitis, gastric perforation, and catheter migration (3). Deaths have been reported after delayed recognition of gastrostomy tube migration (4).
Gastrojejunal tubes frequently are placed in patients when they have tracheal aspiration, gastroparesis and partial gastrectomies, and complications similar to those mentioned previously (5). Obstruction of the antrum by migration of the internal balloon of the gastrostomy button (5) and duodenal obstruction by migration of Foley catheter bulb used for feeding have also been described (6). To our knowledge, there have been no similar reported cases in the literature. In this patient with presumed shunt malfunction, multiple VPS revisions did not relieve symptoms until the gastrostomy tube balloon was replaced at its correct location. Although the findings of the shunt series and computed tomography scan of the brain in our patient seemed to suggest proper shunt function, surgical intervention was performed. As many as one third of the patients presenting with shunt malfunction may not have this diagnosis supported by a prospective radiologic interpretation of a brain imaging study (7). Therefore, the decision to determine the need for surgery rests in the hands of the neurosurgeon. Clinical and radiologic evaluations may not be reliable; therefore, repeated revisions may need to be performed (8,9). A high index of suspicion for gastrojejunal tube malfunction or malpositioning must be maintained, and these patients must be evaluated for intestinal obstruction when recurrent emesis is a complaint at presentation. Clinical history and physical examination should be directed toward ascertaining the previous external length of the tube (by measurement or by a mark with indelible ink). If this is not possible, it may be necessary to eliminate this as a possibility by radiologic evaluation before consideration of additional invasive procedures.
Physicians always should check for such potential migration of the gastrojejunal tubes and exclude obstruction before to subjecting patients to surgical intervention for presumed increased intracranial pressure. Migration of the feeding tube and subsequent obstruction can be prevented either by placing a retention device externally or by a mark with indelible ink on the tube, which must be visible at all times to the caregiver. Proper instructions for care of gastrojejunal tube are mandatory for preventing such mishaps. In conclusion, awareness and early recognition of the potential complications associated with enteral tubes using a team approach is vital for successful management and prevention of morbidity and mortality in these patients.
1. Khattak IU, Kimber C, Kiely EM, et al. Percutaneous endoscopic gastrostomy in paediatric practice: complications and outcome. J Ped Surg 1998; 33:67–72.
2. Chit PG, Weinberg J, Connolly BL, et al. Retrograde percutaneous gastrostomy and gastrojejunostomy in 505 children: a 4–1/2 year experience. Radiology 1996; 201:691–5.
3. Fox VL, Abel SD, Malas S, et al. Complications following percutaneous endoscopic gastrostomy and subsequent catheter replacement in children and young adults. Gastrointest Endosc 1997; 45:64–71.
4. Botterill I, Miller G, Dexter S, et al. Lesson of the week: deaths after delayed recognition of percutaneous endoscopic gastrostomy tube migration. BMJ 1998; 317:524–5.
5. Peters JM, Simpson P, Tolia V. Experience with Gastrojejunal tubes in Children. Am J Gastroenterol 1997; 92:476–80.
6. Tibbitts GM, Sorrell RJ. Duodenal obstruction from a Gastric feeding tube (letter). New Eng J Med 1999; 340:970–1.
7. Iskandar BJ, McLaughlin C, Mapstone TB, et al. Pitfalls in the diagnosis of ventricular shunt dysfunction: radiology reports and ventricular size. Pediatrics 1998; 101:1031–6.
8. Murtagh FR, Quencer RM, Poole CA. Cerebrospinal fluid shunt function and hydrocephalus in the pediatric age group: a radiographic and clinical correclation. Radiology
9. Piatt Jr. JH Physical examination of patients with cerebrospinal fluid shunts: is there useful information in pumping the shunt? J Pediatr 1992; 89:470–3.