Case Report: The Hungry, Hungry Haustra: The Case of a Missing Feeding Tube

Introduction

Percutaneous endoscopic gastrostomy (PEG) tubes are a common method employed for long-term feeding in patients who are unable to tolerate oral feedings.¹ Though PEG-tube placement is a common, safe, and well-studied practice, there are known complications, including wound infection, dislodgement, and peritonitis.² Dislodgement and recurrent ED visits are increasingly becoming a burden on both patients and healthcare providers, as up to 12.8% of patients will require ED replacement of a dislodged tube, totaling an estimated $1,200 per visit.³

Newer techniques include Roux-en-Y feeding jejunostomy tubes, which are anticipated to reduce long-term compli­cations.^4,5 However, dislodgement, sinus tracts, and superimposed infections still occur, also leading to ED visits.⁶ Foley catheters are a readily available and low-cost alternative to replace commercial feeding-tubes in the ED, and are commonly used when the original feeding-tube is not suitable for reuse.⁷ In the following presentation, the authors describe a previously unseen case of a fully intussuscepted Foley catheter though a Roux-en-Y jejunostomy.

Case Report

A 69-year-old man, recently diagnosed with invasive squamous cell carcinoma of the distal esophagus, presented to the ED with a chief complaint of “J-tube fell out.” One month prior to presentation, the patient had undergone a laparoscopic Janeway Roux-en-Y nipple jejunostomy. He had been previously evaluated several times in the ED for a displaced J-tube, and his commercial feeding tube had been replaced with a Foley catheter without incident.

On this visit, the patient’s wife reported that the Foley catheter had become displaced 3 days prior to presentation, and she assumed that the patient had accidentally pulled it out. According to the patient’s wife, he had attempted oral feedings, but had difficulty swallowing as well as coughing episodes.

Upon initial evaluation, the patient complained of diffuse abdominal pain and cramping. He denied any nausea or vomiting, and reported normal bowel movements. The physical examination was remarkable for the following: hypotension (blood pressure, 64/46 mm Hg); heart rate, 94 beats/minute; temperature, 96.4°F; cachexia; a diffusely tender abdomen; and viable stoma on the anterior abdominal wall. Purulent and malodorous drainage was noted at the stoma site. There was no Foley catheter or J-tube in place, and neither the patient nor his wife had brought the dislodged tube to the ED.

The patient was given a normal saline bolus of 2 L and 100 mcg of fentanyl for his pain. Laboratory studies were obtained and were remarkable for the following: sodium, 162 mEq/L; blood urea nitrogen, 44 mg/dL; creatinine, 1.2 mg/dL (which was 100% of patient’s baseline); and white blood cell count, 11.4 x 10⁹/L. Broad spectrum antibiotics of intravenous (IV) piperacillin-tazobactam and vancomycin were initiated and an NG-tube was placed.

A computed tomography scan of the patient’s abdomen and pelvis were ordered with IV and oral contrast. The imaging studies revealed multiple dilated, fluid-filled loops of small bowel, and a Foley catheter proximal to the ileocecal valve, with the balloon still inflated (Figure).

The emergency physician notified the original surgical team of the patient’s status. The surgical team placed a new, 14 French (Fr)-Foley catheter through the stoma, sutured it in place, and admitted the patient to their service. The patient was maintained on IV antibiotics and fluids. As he continued to pass flatus and stool, a diet was advanced through the replacement Foley catheter. The intussuscepted Foley was subsequently passed naturally on day 4 of his hospital admission. The patient unfortunately died several days later of hypoxic respiratory failure, which was not thought to be related to the ingested catheter.

Discussion

Percutaneous Foley catheters, either pre- or postpyloric, have been used for decades as permanent feeding tubes for patients unable to tolerate oral feedings. These catheters are well-known to be inexpensive and safe replacements for commercial gastrostomy tubes.⁷ However, a number of complications unique to Foley feeding tubes have been described in case reports, including mechanical obstruction leading to pancreatitis, duodenal obstruction, bowel ischemia secondary to balloon overfilling, pyloric obstruction, bowel infection, as well as broken and digested catheters.^8-10

Interestingly, despite multiple case reports demonstrating tube migration, prospective studies have shown this to be a relatively uncommon complication.¹¹ In 2012, a patient in Israel ingested a Foley catheter via the gastrostomy stoma, resulting in small bowel obstruction relieved only by enterotomy and removal of the catheter. There have been no previous documented reports of ingested tubes via jejunostomy stoma.¹² Significant forces exerted on Foley catheters have been described, resulting in skin necrosis at the hub and stretching of the catheter from the proximal small bowel to the terminal ileum. In this case presentation, bowel peristalsis was able to advance the entire tube through the skin.¹³

 

Management of feeding-Foley-catheter complications typically involves deflation of the balloon and removal and replacement of the offending catheter—usually with a smaller sized Foley catheter (eg, 12Fr, 14Fr, 16Fr). Complicated cases with catheter malfunction have been successfully managed endoscopically.¹⁴ The patient in this case was likely at higher risk of complication given the abnormally large wound surrounding the stoma and skin breakdown secondary to superimposed infection.

Conclusion

This case highlights the potent peristaltic forces that are exerted upon a feeding Foley catheter and reinforces the importance of proper tube anchorage. Although this patient did well with direct skin suturing of the replacement catheter, previous studies recommend using a plastic retention ring. Placing a mark on the outside of the catheter as a means to continuously visualize its proper anchorage and placement has also been suggested in the literature. Additionally, whenever a patient presents with a displaced feeding tube (Foley catheter or commercial tube), providers should not assume that the tube has been displaced externally and should maintain a low-threshold for advanced imaging and/or endoscopy if the tube cannot otherwise be located.

Dr Lefkove is an attending physician in the department of emergency medicine, DeKalb Medical Center, Atlanta, Georgia. Dr Meloy is an assistant professor of emergency medicine at Emory University School of Medicine, Atlanta, Georgia.

Introduction

Percutaneous endoscopic gastrostomy (PEG) tubes are a common method employed for long-term feeding in patients who are unable to tolerate oral feedings.¹ Though PEG-tube placement is a common, safe, and well-studied practice, there are known complications, including wound infection, dislodgement, and peritonitis.² Dislodgement and recurrent ED visits are increasingly becoming a burden on both patients and healthcare providers, as up to 12.8% of patients will require ED replacement of a dislodged tube, totaling an estimated $1,200 per visit.³

Newer techniques include Roux-en-Y feeding jejunostomy tubes, which are anticipated to reduce long-term compli­cations.^4,5 However, dislodgement, sinus tracts, and superimposed infections still occur, also leading to ED visits.⁶ Foley catheters are a readily available and low-cost alternative to replace commercial feeding-tubes in the ED, and are commonly used when the original feeding-tube is not suitable for reuse.⁷ In the following presentation, the authors describe a previously unseen case of a fully intussuscepted Foley catheter though a Roux-en-Y jejunostomy.

Case Report

A 69-year-old man, recently diagnosed with invasive squamous cell carcinoma of the distal esophagus, presented to the ED with a chief complaint of “J-tube fell out.” One month prior to presentation, the patient had undergone a laparoscopic Janeway Roux-en-Y nipple jejunostomy. He had been previously evaluated several times in the ED for a displaced J-tube, and his commercial feeding tube had been replaced with a Foley catheter without incident.

On this visit, the patient’s wife reported that the Foley catheter had become displaced 3 days prior to presentation, and she assumed that the patient had accidentally pulled it out. According to the patient’s wife, he had attempted oral feedings, but had difficulty swallowing as well as coughing episodes.

Upon initial evaluation, the patient complained of diffuse abdominal pain and cramping. He denied any nausea or vomiting, and reported normal bowel movements. The physical examination was remarkable for the following: hypotension (blood pressure, 64/46 mm Hg); heart rate, 94 beats/minute; temperature, 96.4°F; cachexia; a diffusely tender abdomen; and viable stoma on the anterior abdominal wall. Purulent and malodorous drainage was noted at the stoma site. There was no Foley catheter or J-tube in place, and neither the patient nor his wife had brought the dislodged tube to the ED.

The patient was given a normal saline bolus of 2 L and 100 mcg of fentanyl for his pain. Laboratory studies were obtained and were remarkable for the following: sodium, 162 mEq/L; blood urea nitrogen, 44 mg/dL; creatinine, 1.2 mg/dL (which was 100% of patient’s baseline); and white blood cell count, 11.4 x 10⁹/L. Broad spectrum antibiotics of intravenous (IV) piperacillin-tazobactam and vancomycin were initiated and an NG-tube was placed.

A computed tomography scan of the patient’s abdomen and pelvis were ordered with IV and oral contrast. The imaging studies revealed multiple dilated, fluid-filled loops of small bowel, and a Foley catheter proximal to the ileocecal valve, with the balloon still inflated (Figure).

The emergency physician notified the original surgical team of the patient’s status. The surgical team placed a new, 14 French (Fr)-Foley catheter through the stoma, sutured it in place, and admitted the patient to their service. The patient was maintained on IV antibiotics and fluids. As he continued to pass flatus and stool, a diet was advanced through the replacement Foley catheter. The intussuscepted Foley was subsequently passed naturally on day 4 of his hospital admission. The patient unfortunately died several days later of hypoxic respiratory failure, which was not thought to be related to the ingested catheter.

Discussion

Percutaneous Foley catheters, either pre- or postpyloric, have been used for decades as permanent feeding tubes for patients unable to tolerate oral feedings. These catheters are well-known to be inexpensive and safe replacements for commercial gastrostomy tubes.⁷ However, a number of complications unique to Foley feeding tubes have been described in case reports, including mechanical obstruction leading to pancreatitis, duodenal obstruction, bowel ischemia secondary to balloon overfilling, pyloric obstruction, bowel infection, as well as broken and digested catheters.^8-10

Interestingly, despite multiple case reports demonstrating tube migration, prospective studies have shown this to be a relatively uncommon complication.¹¹ In 2012, a patient in Israel ingested a Foley catheter via the gastrostomy stoma, resulting in small bowel obstruction relieved only by enterotomy and removal of the catheter. There have been no previous documented reports of ingested tubes via jejunostomy stoma.¹² Significant forces exerted on Foley catheters have been described, resulting in skin necrosis at the hub and stretching of the catheter from the proximal small bowel to the terminal ileum. In this case presentation, bowel peristalsis was able to advance the entire tube through the skin.¹³

 

Management of feeding-Foley-catheter complications typically involves deflation of the balloon and removal and replacement of the offending catheter—usually with a smaller sized Foley catheter (eg, 12Fr, 14Fr, 16Fr). Complicated cases with catheter malfunction have been successfully managed endoscopically.¹⁴ The patient in this case was likely at higher risk of complication given the abnormally large wound surrounding the stoma and skin breakdown secondary to superimposed infection.

Conclusion

This case highlights the potent peristaltic forces that are exerted upon a feeding Foley catheter and reinforces the importance of proper tube anchorage. Although this patient did well with direct skin suturing of the replacement catheter, previous studies recommend using a plastic retention ring. Placing a mark on the outside of the catheter as a means to continuously visualize its proper anchorage and placement has also been suggested in the literature. Additionally, whenever a patient presents with a displaced feeding tube (Foley catheter or commercial tube), providers should not assume that the tube has been displaced externally and should maintain a low-threshold for advanced imaging and/or endoscopy if the tube cannot otherwise be located.

Dr Lefkove is an attending physician in the department of emergency medicine, DeKalb Medical Center, Atlanta, Georgia. Dr Meloy is an assistant professor of emergency medicine at Emory University School of Medicine, Atlanta, Georgia.

Introduction

Percutaneous endoscopic gastrostomy (PEG) tubes are a common method employed for long-term feeding in patients who are unable to tolerate oral feedings.¹ Though PEG-tube placement is a common, safe, and well-studied practice, there are known complications, including wound infection, dislodgement, and peritonitis.² Dislodgement and recurrent ED visits are increasingly becoming a burden on both patients and healthcare providers, as up to 12.8% of patients will require ED replacement of a dislodged tube, totaling an estimated $1,200 per visit.³

Newer techniques include Roux-en-Y feeding jejunostomy tubes, which are anticipated to reduce long-term compli­cations.^4,5 However, dislodgement, sinus tracts, and superimposed infections still occur, also leading to ED visits.⁶ Foley catheters are a readily available and low-cost alternative to replace commercial feeding-tubes in the ED, and are commonly used when the original feeding-tube is not suitable for reuse.⁷ In the following presentation, the authors describe a previously unseen case of a fully intussuscepted Foley catheter though a Roux-en-Y jejunostomy.

Case Report

A 69-year-old man, recently diagnosed with invasive squamous cell carcinoma of the distal esophagus, presented to the ED with a chief complaint of “J-tube fell out.” One month prior to presentation, the patient had undergone a laparoscopic Janeway Roux-en-Y nipple jejunostomy. He had been previously evaluated several times in the ED for a displaced J-tube, and his commercial feeding tube had been replaced with a Foley catheter without incident.

On this visit, the patient’s wife reported that the Foley catheter had become displaced 3 days prior to presentation, and she assumed that the patient had accidentally pulled it out. According to the patient’s wife, he had attempted oral feedings, but had difficulty swallowing as well as coughing episodes.

Upon initial evaluation, the patient complained of diffuse abdominal pain and cramping. He denied any nausea or vomiting, and reported normal bowel movements. The physical examination was remarkable for the following: hypotension (blood pressure, 64/46 mm Hg); heart rate, 94 beats/minute; temperature, 96.4°F; cachexia; a diffusely tender abdomen; and viable stoma on the anterior abdominal wall. Purulent and malodorous drainage was noted at the stoma site. There was no Foley catheter or J-tube in place, and neither the patient nor his wife had brought the dislodged tube to the ED.

The patient was given a normal saline bolus of 2 L and 100 mcg of fentanyl for his pain. Laboratory studies were obtained and were remarkable for the following: sodium, 162 mEq/L; blood urea nitrogen, 44 mg/dL; creatinine, 1.2 mg/dL (which was 100% of patient’s baseline); and white blood cell count, 11.4 x 10⁹/L. Broad spectrum antibiotics of intravenous (IV) piperacillin-tazobactam and vancomycin were initiated and an NG-tube was placed.

A computed tomography scan of the patient’s abdomen and pelvis were ordered with IV and oral contrast. The imaging studies revealed multiple dilated, fluid-filled loops of small bowel, and a Foley catheter proximal to the ileocecal valve, with the balloon still inflated (Figure).

The emergency physician notified the original surgical team of the patient’s status. The surgical team placed a new, 14 French (Fr)-Foley catheter through the stoma, sutured it in place, and admitted the patient to their service. The patient was maintained on IV antibiotics and fluids. As he continued to pass flatus and stool, a diet was advanced through the replacement Foley catheter. The intussuscepted Foley was subsequently passed naturally on day 4 of his hospital admission. The patient unfortunately died several days later of hypoxic respiratory failure, which was not thought to be related to the ingested catheter.

Discussion

Percutaneous Foley catheters, either pre- or postpyloric, have been used for decades as permanent feeding tubes for patients unable to tolerate oral feedings. These catheters are well-known to be inexpensive and safe replacements for commercial gastrostomy tubes.⁷ However, a number of complications unique to Foley feeding tubes have been described in case reports, including mechanical obstruction leading to pancreatitis, duodenal obstruction, bowel ischemia secondary to balloon overfilling, pyloric obstruction, bowel infection, as well as broken and digested catheters.^8-10

Interestingly, despite multiple case reports demonstrating tube migration, prospective studies have shown this to be a relatively uncommon complication.¹¹ In 2012, a patient in Israel ingested a Foley catheter via the gastrostomy stoma, resulting in small bowel obstruction relieved only by enterotomy and removal of the catheter. There have been no previous documented reports of ingested tubes via jejunostomy stoma.¹² Significant forces exerted on Foley catheters have been described, resulting in skin necrosis at the hub and stretching of the catheter from the proximal small bowel to the terminal ileum. In this case presentation, bowel peristalsis was able to advance the entire tube through the skin.¹³

 

Management of feeding-Foley-catheter complications typically involves deflation of the balloon and removal and replacement of the offending catheter—usually with a smaller sized Foley catheter (eg, 12Fr, 14Fr, 16Fr). Complicated cases with catheter malfunction have been successfully managed endoscopically.¹⁴ The patient in this case was likely at higher risk of complication given the abnormally large wound surrounding the stoma and skin breakdown secondary to superimposed infection.

Conclusion

This case highlights the potent peristaltic forces that are exerted upon a feeding Foley catheter and reinforces the importance of proper tube anchorage. Although this patient did well with direct skin suturing of the replacement catheter, previous studies recommend using a plastic retention ring. Placing a mark on the outside of the catheter as a means to continuously visualize its proper anchorage and placement has also been suggested in the literature. Additionally, whenever a patient presents with a displaced feeding tube (Foley catheter or commercial tube), providers should not assume that the tube has been displaced externally and should maintain a low-threshold for advanced imaging and/or endoscopy if the tube cannot otherwise be located.

Dr Lefkove is an attending physician in the department of emergency medicine, DeKalb Medical Center, Atlanta, Georgia. Dr Meloy is an assistant professor of emergency medicine at Emory University School of Medicine, Atlanta, Georgia.