Complication of a percutaneous endoscopic gastrostomy tube causing duodenal ischemia.

A 33-year-old woman with a percutaneous endoscopic gastrostomy tube was admitted with bilious vomiting, 1 month after her feeding tube was replaced by a temporary Foley catheter. A computed tomography scan of her abdomen revealed a 4.5 cm by 7.5 cm fluid-filled structure in the distal duodenum surrounding the Foley feeding tube. Approximately 100 mL of fluid was aspirated from the Foley's balloon port. We hypothesized that the Foley catheter was flushed inappropriately through the balloon port, causing an iatrogenic ischemic duodenal injury. Conservative management was successful in the intensive care unit. This case highlights an unusual complication of percutaneous endoscopic gastrostomy tubes. In addition, it emphasizes the temporary nature of Foley catheters as replacement gastrostomy tubes, and the importance of training in the handling of feeding tubes.