Small bowel intussusception secondary to gastrostomy is a rare complication. Percutaneous endoscopic gastrostomy (PEG) tube placement is a very safe procedure with a notably low mortality rate of 0–2%.1 The incidence of intussusception in adults is generally less than 5%, but it is far more common in pediatric patients.2 The main cases are secondary to organic diseases, such as malignant or benign gastrointestinal tumors, Meckel’s diverticulum, lipomas, polyps, and gastrostomy with jejunal extension placement, particularly in the pediatric population.2–4 Most cases are resolved surgically, but endoscopy may be performed in certain specific scenarios when no evidence of intestinal ischemia is found.4–9 Herein, we report a case of jejunojejunal intussusception caused by a migrated temporary gastrostomy tube.

A 60-year-old male patient had a history of type 2 diabetes mellitus and prior hospitalization for a deep neck abscess, further complicated by mediastinitis and the placement of a PEG feeding tube for a swallowing disorder secondary to prolonged ventilation. He was admitted to an outpatient clinic due to the accidental dislodgment of the gastrostomy tube seven weeks after its placement. A provisional Foley catheter was inserted in place of the PEG tube to maintain the patency of the gastrostomy access, considering the patient’s prior unsuccessful swallowing assessment. Unfortunately, the patient was lost to follow-up after this procedure. He returned to the emergency room two months later, presenting with severe abdominal pain, nausea, vomiting, and poor tolerance to oral and gastrostomy feeding attempts.

Physical examination revealed that the provisional Foley-gastrostomy catheter appeared to have migrated forward, making it impossible to mobilize and rotate, causing severe pain during the relocation attempts. An abdominal computed tomography (CT) scan revealed that the Foley catheter had migrated and become stuck in the proximal jejunum, a development associated with early signs of ischemia (Figs. 1 and 2). Urgent surgery was performed, identifying a jejunojejunal intussusception at 20 inches distal to the angle of Treitz, secondary to the Foley catheter migration.

Figure 1.

Axial computed tomography scan confirming the migrated gastrostomy Foley catheter.

Figure 2.

Sagittal computed tomography scan showing the Foley catheter in the proximal jejunum.

Laparotomy revealed early ischemic signs in the intestinal wall. They improved immediately after the catheter was removed and the intestinal intussusception was manually freed, thus making intestinal resection unnecessary (Fig. 3). Subsequently, the patient underwent an endoscopy, during which two ulcers were noted in the second part of the duodenum, possibly related to catheter migration. A 24 Fr PEG tube was then placed via the pull technique (Fig. 4). Standard proton pump inhibitor therapy was commenced to stimulate ulcer healing. On his latest follow-up visit seven months after the PEG replacement, the patient failed the swallow test for liquids, therefore requiring a combination of oral diet and PEG tube feeding. He continues to perform rehabilitative swallowing exercises and is undergoing physiotherapy.

Figure 3.

The jejunal wall at 20 inches distal to the angle of Treitz, with incipient signs of ischemia.

Figure 4.

Endoscopic image of a Forrest III ulcer in the second part of the duodenum.

Jejunal intussusception secondary to post-pyloric gastrostomy catheter migration is a rare complication related to the use of gastrostomy tubes lacking external fixation, in patients with normal peristalsis, which favors the catheter’s distal migration.4–9 It has been hypothesized that attempts to withdraw the tube while the balloon is inflated could be a contributing factor to the development of intussusception.7 The classic “target”, “doughnut”, and “sausage-shaped” signs on a CT scan are helpful in diagnosing this complication.3,4 Similarly, signs of forward gastrostomy tube migration, including the inability to withdraw the tube, may be associated with abdominal pain and symptoms of gastric outlet obstruction. Transient obstructive jaundice may be present when the catheter migrates to the second part of the duodenum.8

To the best of our knowledge, there have only been eight published cases of jejunal intussusception secondary to Foley catheters used as temporary gastrostomies in adult patients. Most of the cases were jejunoduodenal and jejunoduodenogastric intussusceptions; the majority were treated surgically, as occurred with our patient, and two cases were managed through tube balloon deflation.5–9 The present report is a case of jejunojejunal intussusception secondary to provisional gastrostomy. Intussusception should be considered in patients with this type of tube who experience vomiting, nausea, or abdominal pain, especially when there are changes in the fixation level of the feeding tube.5–9 Early diagnosis and management of intussusception can prevent ischemia and perforation.

Temporary gastrostomy tubes, such as Foley catheters, have been utilized for enteral feeding in developing countries. However, because they are not specifically designed for this purpose, their use can lead to complications, such as tube migration. Therefore, careful monitoring is crucial when using these tubes, and they should be promptly replaced with externally fixed gastrostomy tubes to ensure safety and proper function.10