Case Report
A 52-year-old female presented with a 5-day history of vomiting with epigastric pain. Her past medical history included a previous history of stroke, for which her significant dysphagia resulted in dependence on percutaneous endoscopic gastrostomy (PEG) feeds. She had previously had a laparoscopic cholecystectomy and no alcohol intake. Her PEG tube had been inserted 3 months prior with good tolerance of feeds. However, two weeks prior to this presentation, her tube had blocked at the nursing home, and replaced bedside. Unfortunately, radiological confirmation of positioning was not performed at this time prior to usage of the PEG for feeds.
On examination she was maximally tender in the epigastrium. Her bloods demonstrated a lipase of 7365U/L (upper limit of normal being 60U/L), alkaline phosphatase 140U/L, y-glutamyl transferase 117U/L, alanine aminotransferase 98U/L, aspartate aminotransferase 78 U/L and bilirubin of 5umol/L. Her white cell count and C reactive protein were 15.7 and 49, respectively. Her triglycerides, immunoglobulin G subtypes, and calcium levels were within normal ranges. Contrast enhanced computed tomography of the abdomen demonstrated a PEG tube and balloon in the region of the second part of the duodenum with associated oedema of the pancreas without any evidence of significant biliary dilatation (Figures 1 and 2). A Magnetic Resonance Cholangiopancreatography (MRCP) was performed to ensure nil other causes of ductal obstruction, and it showed evidence of uncomplicated interstitial pancreatitis without evidence of other ductal pathology (Figure 3). She had no other obvious indicators of causes for the pancreatitis other than the PEG tube balloon in the duodenum. The patient’s balloon was deflated and pulled back 10cm with subsequent CT imaging confirming appropriate position in the stomach. Her symptoms and inflammatory markers improved following readjustment of the PEG tube, and after a period of monitoring, she was successfully discharged.