Reply to Migration of Percutaneous Endoscopic Gastrostomy Tube in Children
To the Editors:
We appreciate the comments of Drs. Uhlen et al. These two cases further highlight the potential complications of gastric feeding tubes in children. Dr. Uhlen's point regarding early diagnosis at presentation, secondary to migration of gastric balloon in non-verbal children with multiple medical problems is well taken. Fortunately, their first case was diagnosable by plain abdominal x-ray, so manipulation of tube placement quickly resolved the situation without additional morbidity. This patient's clinical presentation was similar to our neurologically compromised patient who was suspected to have a shunt malfunction. (1) Furthermore, our patient did have gastroesophageal reflux, which was exacerbated leading to significant hematemesis, warranting diagnostic endoscopy on an emergent basis, when the problem was diagnosed. Their second case however, is unusual, because migration of redundant gastric tube is usually distal with the peristalsis, and in this patient it went retrograde. Moreover, it had lodged in that position for a while possibly causing pressure necrosis and fistula formation, which proved to be fatal. No mention was made whether the tube was positioned in proximal stomach and hence such a migration. We have seen another case of migration of gastric balloon of gastrojejunostomy tube in a three-year-old patient who presented with recurrent vomiting and abdominal pain. This patient was neurologically intact and complained of severe abdominal pain. In the emergency room, a plain x-ray revealed the migration of the balloon and of course, the problem was resolved quickly as in the first case of Uhlen et al. The lesson from such cases is that a screening abdominal film should be the initial diagnostic test in patients with gastric or gastroenteric tubes who present with persistent vomiting. Their caretakers should also be counseled regarding knowing the specific length of the tube that should be externally visible to suspect migration.
Rajiv Kaddu, MD
Vasundhara Tolia, MD
1. Kaddu R, Tolia V. Gastrostomy button migration into the duodenal bulb mimicking ventriculoperitoneal shunt malfunction. J Pediatr Gastroenterol Nutr 2001; 32:212–4.