How should I manage a patient with chronic ileus on percutaneous endoscopic gastrostomy (PEG) tube feeds who now presents with abdominal distension and guarding?

Management of Acute Abdomen in a Patient with Chronic Ileus on PEG Feeds

This patient requires immediate cessation of PEG feeds, urgent surgical consultation, and imaging to rule out peritonitis, perforation, or other life-threatening complications—abdominal distension with guarding in a PEG-fed patient with chronic ileus represents a surgical emergency until proven otherwise.

Immediate Actions

Stop All Enteral Feeding

• Immediately discontinue all PEG tube feeds to prevent further gastric distension and potential aspiration or worsening of any intra-abdominal pathology 1.
• Place the patient NPO (nothing per os) until the acute process is identified and managed 1.

Urgent Surgical Evaluation

• Obtain immediate surgical consultation as abdominal guarding suggests peritoneal irritation, which may indicate perforation, peritonitis, or bowel ischemia requiring operative intervention 1.
• Acute severe complications such as perforation, serious abdominal hemorrhage, or peritonitis occur in fewer than 0.5% of PEG cases but require surgical intervention when present 1.

Diagnostic Imaging

• Order urgent CT scan of the abdomen and pelvis with oral and IV contrast to evaluate for:
  • Free air indicating perforation 1
  • Colocutaneous fistula (PEG tube inadvertently placed through colon) 2
  • Bowel obstruction or ileus progression 3
  • Intra-abdominal abscess or fluid collections 1
  • Buried bumper syndrome with peritoneal involvement 1

Critical Differential Diagnoses to Exclude

PEG-Related Catastrophic Complications

• Inadvertent colon perforation: The PEG tube may have been placed through the transverse colon into the stomach, which can present with delayed symptoms including distension and peritonitis 2.
• Gastric or bowel perforation: Complete laceration occurs in 0.5-1.3% of cases and can present with peritonitis 1.
• Buried bumper syndrome with peritoneal involvement: The internal bumper can erode through the gastric wall causing peritonitis 1.

Ileus-Related Complications

• Mechanical obstruction: Chronic ileus patients are at risk for progression to complete obstruction, particularly if there is underlying adhesive disease 3.
• Constipation-induced complications: Severe constipation increases intra-abdominal pressure and is a known risk factor for PEG complications including leakage and peritonitis 1.

Infection and Inflammation

• Peritonitis: Can occur from PEG-related perforation, leakage of gastric contents, or progression of peristomal infection 1.
• Intra-abdominal abscess: May develop from chronic leakage around the PEG site or from bowel perforation 1.

Physical Examination Priorities

Assess Severity of Peritoneal Signs

• Evaluate the quality and extent of guarding: Voluntary guarding versus involuntary rigidity—the latter indicates established peritonitis requiring urgent surgery 1.
• Check for rebound tenderness, which further confirms peritoneal irritation 1.

Inspect the PEG Site

• Examine for peristomal infection: Erythema, purulence, induration, or excessive leakage of gastric contents 1.
• More than 5 mm of reddening around the stoma suggests infection rather than simple mechanical irritation 1.
• Check external bolster tension—excessive pressure can cause buried bumper syndrome and tissue necrosis 1.

Systemic Assessment

• Monitor vital signs for fever, tachycardia, hypotension indicating sepsis or hypovolemia 1.
• Assess for signs of aspiration (hypoxia, respiratory distress) which complicates 0.3-1.0% of PEG cases 1.

Laboratory Evaluation

• Complete blood count: Leukocytosis suggests infection or peritonitis 1.
• Comprehensive metabolic panel: Assess electrolyte derangements from ileus and guide resuscitation 3.
• Lactate level: Elevated lactate may indicate bowel ischemia or sepsis 3.
• Coagulation studies: If surgical intervention is anticipated 1.

Initial Resuscitation

Fluid and Electrolyte Management

• Initiate aggressive IV fluid resuscitation to restore fluid and electrolyte balance, as distension from obstruction or ileus causes third-spacing and dehydration 3.
• Correct electrolyte abnormalities before any potential surgical intervention 3.

Gastric Decompression

• Consider nasogastric tube placement for gastric decompression if the PEG tube cannot adequately decompress the stomach 3.
• Do NOT use the PEG tube for decompression if there is concern for perforation or fistula 2.

Broad-Spectrum Antibiotics

• Administer empiric broad-spectrum antibiotics immediately if peritonitis or intra-abdominal infection is suspected 1.
• Cover gram-negative and anaerobic organisms typical of gastrointestinal flora 1.

Management Based on Imaging Findings

If Perforation or Peritonitis Confirmed

• Proceed to emergency laparotomy or laparoscopy for source control 1, 3.
• Remove the PEG tube if it is the source of perforation 1.
• Repair any bowel injuries and perform peritoneal washout 1.

If Colocutaneous Fistula Identified

• Remove the PEG tube as it is traversing the colon, which causes chronic contamination and diarrhea 2.
• The fistula tract typically closes spontaneously after tube removal 2.
• Consider temporary parenteral nutrition until the tract heals and a new PEG can be safely placed at a different site 2.

If Buried Bumper Syndrome

• Attempt endoscopic removal using a needle knife sphincterotome if the patient is stable 1.
• If peritonitis is present or endoscopic removal fails, surgical removal is required 1.

If Severe Ileus Without Perforation

• Continue conservative management with bowel rest, nasogastric decompression, and IV fluids 3.
• Address underlying causes of ileus (medications, electrolyte abnormalities, constipation) 3.
• Do not resume PEG feeds until ileus resolves and bowel function returns 3.

Common Pitfalls to Avoid

• Do not assume pneumoperitoneum is benign: While pneumoperitoneum occurs in more than 50% of cases after PEG placement and is usually benign, in the setting of guarding and distension it must be assumed pathologic until proven otherwise 1.
• Do not delay imaging for "conservative management": Even though guidelines suggest initial conservative treatment for abdominal pain after PEG placement, guarding is a red flag requiring urgent imaging 1.
• Do not resume feeds without identifying the cause: Restarting feeds before resolving the underlying pathology can worsen perforation, peritonitis, or ileus 3.
• Do not overlook colocutaneous fistula: This complication can be missed on initial endoscopy if only the gastric placement is verified without recognizing colonic interposition 2.

Disposition

• Admit to surgical service for close monitoring and potential operative intervention 1, 3.
• If imaging reveals no surgical pathology, admit to medicine with surgical consultation available 1.
• Serial abdominal exams every 4-6 hours to detect clinical deterioration 1.