Management of a large percutaneous endoscopic gastrostomy tube-associated gastric ulcer with endoscopic suturing

Insertion of a percutaneous endoscopic gastrostomy (PEG) tube is a common procedure performed predominantly for provision of enteral nutrition. Serious complications requiring intervention are reported in 0.4 %–4.4 % of cases [1]. Among these, PEG-associated gastric ulcers are a rare complication, thought to be secondary to pressure necrosis, which can predispose to upper gastrointestinal bleeding [2]. Like other gastric ulcers, these can be treated with conventional endoscopic therapy; however, when treatment is unamenable or fails, endoscopic suturing provides a novel management option that has been described in a few case reports with good results [3] [4].

A 47-year-old woman receiving longstanding enteral feeding through a PEG with jejunal extension presented with anemia (hemoglobin 89 g/L) and suspected upper gastrointestinal bleeding. Gastroscopy showed a 3-cm PEG-associated ulcer ([Fig. 1]) with a visible vessel. The PEG was removed, but conventional endoscopic therapy was unsuccessful. She subsequently underwent vessel cauterization with a heater probe under red dichromatic imaging (RDI), followed by endoscopic suturing using the Apollo OverStitch Sx ([Video 1]). At follow-up endoscopy 6 weeks later, there was evidence of successful ulcer healing, with the sutures still in situ ([Fig. 2]).

Fig. 1 Endoscopic images showing a percutaneous endoscopic gastrostomy (PEG) tube-associated gastric ulcer: a with the PEG in situ; b after removal of the PEG.

Video 1 A percutaneous endoscopic gastrostomy (PEG)-associated ulcer on the anterior stomach wall is treated with a heater probe to the vessel using red dichromatic imaging (RDI), then by endoscopic suturing with a continuous running suture followed by a cross suture.

Fig. 2 Endoscopic image 6 weeks after endoscopic suturing showing complete gastric ulcer healing, with evidence of residual sutures present.

Endoscopic suturing using the Apollo OverStitch Sx is a safe and effective technique for the management of gastric ulcers that are not amenable to or fail conventional endoscopic therapy.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: Techniques, problems and solutions. World J Gastroenterol 2014; 20: 8505-8524
• 2 Shah MJ, Shahidullah AB. Gastric ulcer from the pressure of a gastrostomy tube: A rare cause of upper gastrointestinal bleeding. Cureus 2018; 10: e2783
• 3 Liu S, Kim R. Successful closure with endoscopic suturing of a recalcitrant marginal ulcer despite Roux-en-Y gastric bypass reversion. VideoGIE 2019; 4: 554-555
• 4 Chiu PWY, Chan FKL, Lau JYW. Endoscopic suturing for ulcer exclusion in patients with massively bleeding large gastric ulcer. Gastroenterology 2015; 149: 29-30

Publication History

Article published online:
30 August 2023