Case Presentation

A 34-year-old male with severe scoliosis, neurodisability, immobility, and significant weight loss was admitted to our hospital with six weeks of profuse diarrhea and subsequent hypokalemia. Prior stool cultures were negative for common infectious pathogens. The patient had been receiving enteral nutrition via a PEG tube placed three years earlier without complications, and confirmed intragastric position of the PEG plate. Enteral feeding had been well tolerated since that time.

Index esophagogastroduodenoscopy (EGD) and colonoscopy demonstrated complete intraluminal migration of the PEG into the colon. Computed tomography (CT) confirmed colonic migration of the PEG, showing contrast filling the descending colon. The PEG tube was removed, and the colonic fistulous opening was closed using multiple through-the-scope clips (TTSCs). Owing to an unfavorable anatomic configuration resulting from severe scoliosis (specifically, a retrohepatic/retrocardiac stomach with interposed colon), replacement of the PEG was deemed unsafe by both endoscopic and radiologic assessment. A nasogastric tube was inserted for temporary enteral access. Subsequently, a surgical fine-needle catheter jejunostomy (FKJ) was placed for permanent enteral access. Due to persistent intolerance of enteral nutrition, long-term parenteral nutrition via an implanted port was initiated.

During follow-up, recurrent feculent drainage from the stomach prompted repeat endoscopic evaluation. Combined EGD and colonoscopy revealed a reopened gastrocolic fistula with migration of the nasogastric tube into the colon. The fistula was successfully closed using TTSCs on the colonic side and an over-the-scope clip (OTSC) on the gastric side. Post-intervention imaging confirmed complete closure of the fistula without contrast leakage. Retrospectively, it must be assumed that at initial PEG placement an interposed colon was punctured and traversed by the PEG tube, despite correct intragastric positioning of the PEG plate.

Conclusion

In patients with severe scoliosis, PEG placement should prompt consideration of adjunctive imaging to verify appropriate anatomical positioning and prevent unrecognized transcolonic placement.