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.