Downloaded from http://emj.bmj.com/ on July 21, 2015 - Published by group.bmj.com
PostScript Provenance and peer review Not commissioned; internally peer reviewed.
To cite Murphy CE. Emerg Med J 2014;31:1029– 1030.
REFERENCES 1
Accepted 28 March 2014 Published Online First 17 April 2014
2
Emerg Med J 2014;31:1029–1030. doi:10.1136/emermed-2014-203825
3
The ProCESS investigators. A randomized trial of protocolbased care for early septic shock. New Eng J Med 2014. Knopp R, Claypool R, Leonardi D. Use of the tilt test in measuring acute blood loss. Ann Emerg Med 1980;9:72–5. Water with sugar and salt. Lancet 1978;2:300–1.
IMAGES IN EMERGENCY MEDICINE
Small bowel obstruction in a woman with a missing percutaneous endoscopic gastrostomy tube CASE DESCRIPTION An 87-year-old bedridden, demented woman who was enterally fed via a percutaneous endoscopic gastrostomy (PEG) tube presented to the ED with vomiting, abdominal pain and fever (38.3°C), and a surgical consult was requested from the senior surgical resident. The patient had been referred to the emergency department 3 days earlier due to a missing PEG tube. The patient was seen by a surgical resident, and an 18F Foley catheter was inserted into the gastrostomy site. A plain abdominal X-ray on her repeat visit showed a distal small bowel obstruction with an evident intraluminal migrated PEG tube (figure 1). The patient underwent an emergency laparotomy, which revealed an obstruction just proximal to the ileocecal valve with a patch of full-thickness necrosis of the ileum. An enterotomy revealed the Foley catheter with a still inflated balloon (figure 2). An ileocecectomy was performed, and her postoperative course was uneventful. Small bowel obstruction by migrated gastrostomy feeding tubes is a rare complication mostly occurring in the duodenum or jejunum.1 This case’s severe presentation emphasises the importance of tube fixation to the stoma site using an external stop device, routine assessment of the tube’s placement by the nursing staff and consideration of imaging in cases where the gastrostomy tube is missing.
Figure 2 Extraction of the percutaneous endoscopic gastrostomy with a still-inflated balloon via an enterotomy performed on region of focal necrosis.
Avinoam Nevler,1,2 Moshe Zilberman3 1
Department of General Surgery and Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel (Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel) 2 The Dr. Pinchas Borenstein Talpiot Medical Leadership Program 2012, Chaim Sheba Medical Center, Tel-Hashomer, Israel 3 Department of General Surgery, The Baruch Padeh Medical Center, Poria, Lower Galilee, Israel Correspondence to Dr Avinoam Nevler, Department of General Surgery B, Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel; [email protected] Contributors AN and MZ looked after the patient and wrote the draft. Both authors approved the submission of the manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Nevler A, Zilberman M. Emerg Med J 2014;31:1030. Accepted 18 December 2013 Published Online First 13 January 2014 Emerg Med J 2014;31:1030. doi:10.1136/emermed-2013-203379
Figure 1 Plain abdominal radiograph showing a small bowel obstruction and the migrated percutaneous endoscopic gastrostomy tube. 1030
REFERENCE 1
Kamar M, Bar-Dayan A, Zmora O, et al. Small bowel obstruction from a dislodged feeding tube. Age Ageing 2004;33:81–2.
Emerg Med J December 2014 Vol 31 No 12
Downloaded from http://emj.bmj.com/ on July 21, 2015 - Published by group.bmj.com
Small bowel obstruction in a woman with a missing percutaneous endoscopic gastrostomy tube Avinoam Nevler and Moshe Zilberman Emerg Med J 2014 31: 1030 originally published online January 13, 2014
doi: 10.1136/emermed-2013-203379 Updated information and services can be found at: http://emj.bmj.com/content/31/12/1030
These include:
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This article cites 1 articles, 1 of which you can access for free at: http://emj.bmj.com/content/31/12/1030#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Small intestine (34) Ethics (372) Pain (neurology) (954) Clinical diagnostic tests (996) Radiology (945) Radiology (diagnostics) (852)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
PostScript Provenance and peer review Not commissioned; internally peer reviewed.
To cite Murphy CE. Emerg Med J 2014;31:1029– 1030.
REFERENCES 1
Accepted 28 March 2014 Published Online First 17 April 2014
2
Emerg Med J 2014;31:1029–1030. doi:10.1136/emermed-2014-203825
3
The ProCESS investigators. A randomized trial of protocolbased care for early septic shock. New Eng J Med 2014. Knopp R, Claypool R, Leonardi D. Use of the tilt test in measuring acute blood loss. Ann Emerg Med 1980;9:72–5. Water with sugar and salt. Lancet 1978;2:300–1.
IMAGES IN EMERGENCY MEDICINE
Small bowel obstruction in a woman with a missing percutaneous endoscopic gastrostomy tube CASE DESCRIPTION An 87-year-old bedridden, demented woman who was enterally fed via a percutaneous endoscopic gastrostomy (PEG) tube presented to the ED with vomiting, abdominal pain and fever (38.3°C), and a surgical consult was requested from the senior surgical resident. The patient had been referred to the emergency department 3 days earlier due to a missing PEG tube. The patient was seen by a surgical resident, and an 18F Foley catheter was inserted into the gastrostomy site. A plain abdominal X-ray on her repeat visit showed a distal small bowel obstruction with an evident intraluminal migrated PEG tube (figure 1). The patient underwent an emergency laparotomy, which revealed an obstruction just proximal to the ileocecal valve with a patch of full-thickness necrosis of the ileum. An enterotomy revealed the Foley catheter with a still inflated balloon (figure 2). An ileocecectomy was performed, and her postoperative course was uneventful. Small bowel obstruction by migrated gastrostomy feeding tubes is a rare complication mostly occurring in the duodenum or jejunum.1 This case’s severe presentation emphasises the importance of tube fixation to the stoma site using an external stop device, routine assessment of the tube’s placement by the nursing staff and consideration of imaging in cases where the gastrostomy tube is missing.
Figure 2 Extraction of the percutaneous endoscopic gastrostomy with a still-inflated balloon via an enterotomy performed on region of focal necrosis.
Avinoam Nevler,1,2 Moshe Zilberman3 1
Department of General Surgery and Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel (Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel) 2 The Dr. Pinchas Borenstein Talpiot Medical Leadership Program 2012, Chaim Sheba Medical Center, Tel-Hashomer, Israel 3 Department of General Surgery, The Baruch Padeh Medical Center, Poria, Lower Galilee, Israel Correspondence to Dr Avinoam Nevler, Department of General Surgery B, Chaim Sheba Medical Center, Tel-Hashomer 52621, Israel; [email protected] Contributors AN and MZ looked after the patient and wrote the draft. Both authors approved the submission of the manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Nevler A, Zilberman M. Emerg Med J 2014;31:1030. Accepted 18 December 2013 Published Online First 13 January 2014 Emerg Med J 2014;31:1030. doi:10.1136/emermed-2013-203379
Figure 1 Plain abdominal radiograph showing a small bowel obstruction and the migrated percutaneous endoscopic gastrostomy tube. 1030
REFERENCE 1
Kamar M, Bar-Dayan A, Zmora O, et al. Small bowel obstruction from a dislodged feeding tube. Age Ageing 2004;33:81–2.
Emerg Med J December 2014 Vol 31 No 12
Downloaded from http://emj.bmj.com/ on July 21, 2015 - Published by group.bmj.com
Small bowel obstruction in a woman with a missing percutaneous endoscopic gastrostomy tube Avinoam Nevler and Moshe Zilberman Emerg Med J 2014 31: 1030 originally published online January 13, 2014
doi: 10.1136/emermed-2013-203379 Updated information and services can be found at: http://emj.bmj.com/content/31/12/1030
These include:
References Email alerting service
Topic Collections
This article cites 1 articles, 1 of which you can access for free at: http://emj.bmj.com/content/31/12/1030#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Small intestine (34) Ethics (372) Pain (neurology) (954) Clinical diagnostic tests (996) Radiology (945) Radiology (diagnostics) (852)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
