Transhepatic Insertion of Percutaneous Endoscopic Gastrostomy Tube

Inadvertent injury to interposing organs during percutaneous endoscopic gastrostomy (PEG) tube placement is a feared complication of this common and generally safe procedure. Transhepatic PEG insertion is likely an underrepresented complication which may be identified incidentally on imaging or present with life-threatening conditions such as sepsis or massive bleeding. Use of ultrasound in patients with known hepatomegaly may possibly help avoid this complication. We hereby report a case of transhepatic PEG insertion, one of 16 only other cases published in the literature, and review the characteristics of the previous reported cases.


Introduction
Enteral feeding is the preferred nutrition route for all patients with a functional gastrointestinal (GI) tract as it preserves the tract's physical and functional integrity [1,2]. Gastrostomy and jejunostomy tubes are the preferred modality for administering enteral nutrition in patients unable to maintain enough oral intake to meet their metabolic needs [3]. PEG placement is preferred over surgical laparoscopic gastrostomy (SLG) placement as risks of general anesthesia are avoided with the former, and a lower risk of minor complications is reported with PEG placement [4].
PEG placement is a generally safe and well-tolerated procedure [5,6]. Contraindications to PEG placement include severe ascites or coagulopathy, shock, sepsis, abdominal wall infection at the planned gastrostomy site, peritonitis, anatomical, and functional disorders of gastric emptying, and organ interposition [7]. Minor complications related to PEG placement include cutaneous PEG site infections, stomal leakage, and PEG tube dislodgement or obstruction. Life-threatening or severe complications are rare and include gastric perforation, peritonitis, vascular or organ trauma, metastatic tumor spread, necrotizing fasciitis, and buried bumper syndrome [7]. Traversing the liver is an extremely rare but very serious complication of PEG tube placement with only 16 previous case reports in the literature [8][9][10][11][12][13][14][15][16][17][18][19][20]. We report a case of transhepatic insertion of a PEG tube in a 92-year-old female incidentally discovered on imaging and review the literature on this complication.

Case Presentation
A 92-year-old African American female with past medical history significant for toxic megacolon for which she underwent a colectomy with an end ileostomy five years prior was admitted to the hospital for failure to thrive for several months. She had no history of dementia or liver disease, and extensive evaluation revealed no etiology for her condition besides poor intake. A decision to supplement her nutrition enterally was made. She underwent a PEG tube placement after a successful trial of nasogastric feeding.
During her PEG tube placement, her upper endoscopy demonstrated no gastric pathology. A pull method with transillumination was used to insert the PEG tube into position. No immediate complications were noted, and the patient was discharged home.
Two weeks later, she presented with fatigue and abdominal discomfort. On examination, her vital signs were stable, her mucous membranes dry, and her ileostomy and PEG sites were normal. Her initial labs demonstrated a normal white cell count, a hemoglobin of 10.6 g/dl (10.7 g/dl pre-procedure), aspartate aminotransferase of 74 U/L (58 U/L pre-procedure), alanine aminotransferase of 74 U/L (28 U/L before procedure), alkaline phosphatase of 108 U/L (30 U/L before procedure), blood urea nitrogen of 128 mg/dl, and creatinine of 2.45 mg/dl (baseline of 1.2 mg/dl). Intravenous hydration was initiated, and a computed tomography (CT) of the abdomen with oral contrast was obtained which incidentally showed that the PEG tube coursed through the left hepatic lobe with no extravasation of enteric contrast or adjacent hematoma ( Figure 1). Given the patient's hemodynamic stability, absence of leak or hematoma, and the need to maintain enteral access given dehydration, a decision to keep the PEG tube in place was done with plans for removal if further complications arose. e PEG tube flushed with no difficulty and was used for enteral nutrition during the patient's inpatient stay.

Discussion
Gastrostomies can be performed under endoscopic, fluoroscopic, or laparoscopic guidance. e former two techniques avoid complications of general anesthesia and hence are preferred to laparoscopic gastrostomy [5]. A "pull" technique is most commonly used for endoscopic placement of gastrostomy tubes. An alternative technique, the "push" method involves anchoring the stomach prior to PEG insertion with T-fasteners, and the gastrostomy tube is inserted transabdominally rather than transorally.
A comprehensive review of the English literature on inadvertent transhepatic or intrahepatic placement of PEG tubes revealed sixteen other cases, summarized in Table 1. All PEG tubes were inserted using the pull technique except for one. Most of the cases involved insertion through the left hepatic lobe which is expected anatomically. Nine cases (56.3%) complained of abdominal pain, one case (6.25%) presented with tube malfunction, and five cases (31.3%) were discovered incidentally. ree cases (18.8%) had associated bleeding, two of which required liver laceration repairs. Five cases (31.3%) underwent laparotomy. Laparotomy findings included presence of a gastrohepatic fistula in 2 cases, complete intrahepatic migration in 1 case, and a liver laceration in 2 cases. No cases reported hepatic necrosis, a theoretical worrisome complication. e incidence of transhepatic or intrahepatic placement of PEG tubes is likely underreported as most patients report abdominal pain at the PEG site postprocedurally that is frequently attributed to postprocedural abdominal wall pain rather than an ominous complication. e patient reported had no theoretical risk factors for inadvertent hepatic injury that have been suggested such as hepatomegaly or obesity [20]. A mild otherwise unexplained transaminitis (>2 times upper limit of normal) was detected with no hemoglobin drop. A high suspicion index is needed to detect this complication, and complaints of abdominal pain with transaminitis or hemoglobin changes in a patient even several weeks from a PEG tube placement should warrant careful evaluation for PEG tube-related complications among other pathologies. It is also prudent to evaluate for hepatomegaly with physical examination prior to PEG insertion, and to consider using an ultrasound to evaluate for the presence of interposed liver tissue during PEG placement if hepatomegaly is noted. Additionally, the use of a "push" technique with the use of an anchoring system pulls the stomach closer to the abdominal wall which could displace the left lobe of the liver and hence result in a lower risk of  In summary, transhepatic insertion of a PEG tube is a serious complication carrying significant morbidity, evidenced by around one-third of patients having to undergo laparotomies as part of the complication's management. Treatment options include keeping the PEG tube in place if it remains functional and no life-threatening complications are noted, or immediate removal if a life-threatening complication such as severe hemorrhage occurs. Concerns with immediate removal would include forming a gastrohepatic fistula. On the other hand, keeping the PEG tube carries the risks of possible migration reported by two cases, and further difficulties with removal. No clear guidelines exist on the management of this complication, and further research is needed to explore the optimal treatment. It seems reasonable, nevertheless, if a transhepatic PEG tube insertion occurs with no hemodynamic changes, significant symptoms, or lab abnormalities, closely observe the patient and continue using the PEG tube.

Consent
Informed consent was obtained from the patient for publication purposes.

Conflicts of Interest
e authors declare that they have no conflicts of interest.

Authors' Contributions
Imam and Simons-Linares have participated equally in preparing the manuscript.