An 80-year-old woman with a nasogastric tube in situ for cerebral infarction sequelae
was referred for percutaneous endoscopic gastrostomy (PEG). The abdominal computed
tomography scan on admission showed that the transverse colon was interposed between
the anterior abdominal wall and the stomach ([Fig. 1]). The usual PEG placement posed a high risk of piercing the transverse colon. A
fluoroscopy-assisted colonoscopy was performed, which showed that the transverse colon
was present in the upper abdomen ([Fig. 2 a]). While maintaining the tip of the colonoscope at the hepatic flexure, the transverse
colon was moved toward the pelvis under fluoroscopic guidance by using a twisting
maneuver of the scope shaft. While the colonoscope was in situ, the esophagogastroduodenoscope
was inserted ([Fig. 2 b]). The stomach was expanded as usual to perform the PEG. PEG feeding was initiated
as usual without problems. When the PEG button was replaced with a new one 6 months
later, no specific abnormalities were observed.
Fig. 1 Abdominal computed tomography showed that the transverse colon was interposed between
the anterior abdominal wall and the stomach.
Fig. 2 Fluoroscopy-assisted colonoscopy to aid percutaneous endoscopic gastrostomy. a A fluoroscopy-assisted colonoscopy showed that the transverse colon was present in
the upper abdomen. Water-soluble contrast medium introduced from the distal end of
the scope was seen. b The transverse colon was moved toward the pelvis under fluoroscopic guidance by using
a twisting maneuver of the scope shaft. While the colonoscope was in situ, the upper
gastrointestinal endoscope was inserted.
A gastrocolocutaneous fistula is a rare complication of PEG [1]
[2]. It results from the interposition of the colon between the anterior abdominal and
gastric walls, so the PEG tube inadvertently passes through the colon into the stomach,
resulting in the development of an iatrogenic fistula. The risk of this complication
increases in cases of megacolon, subphrenic transposition of the colon, a history
of abdominal surgery, or overinflation of the stomach [1]
[2].
Colonoscopy-assisted PEG insertion is slightly different from conventional endoscopic
methods in terms of its approach. To the best of our knowledge, only one study used
both a colonoscope and an esophagogastroduodenoscope for PEG placement [3]. In that report, Tominaga et al. used fluoroscopy to detect sigmoid interposition
between the abdominal wall and the stomach; subsequent evacuation of gas from the
sigmoid using colonoscopy resulted in successful PEG placement. In the present case,
colonoscopy was used to move the transverse colon toward the pelvis under fluoroscopic
guidance. Serious complications can be prevented using this method.
Endoscopy_UCTN_Code_TTT_1AO_2AK
