Unrecognized Gastrostomy Tube Migration Eventually Causing Bowel Obstruction

A 45 year old female initially presented with traumatic evisceration of bowel requiring gastrostomy tube (G-tube) placement. An initial CT showed the G-tube to be in appropriate position. An additional inpatient CT scan performed 2 weeks later for abdominal pain showed unrecognized, and therefore not reported, distal migration of the G-tube to the proximal duodenum without signs of obstruction at that time. Fluoroscopy performed prior to discharge demonstrated the G-tube to be intraluminal; however, the G-tube did not appear to terminate within the stomach, which was not reported. Additional oblique views may have demonstrated the G-tube balloon to be deep within the abdomen rather than opposed to the skin surface. The patient was then discharged. The patient presented 2 weeks later with symptoms of nausea and bilious emesis and CT scan obtained at that time showed the G-tube balloon to be in the proximal jejunum causing obstruction of the more proximal bowel. This case illustrates a likely preventable G-tube malposition related complication due to failure to recognize and report the G-tube's migration on CT and failure to obtain oblique images during the fluoroscopic tube placement verification study.