Jejunal inflammatory granuloma: a complication of direct percutaneous endoscopic jejunostomy.

hospital for follow−up treatment after an intracerebral bleed on 5 February 2002. We placed a percutaneous endoscopic gastrostomy (PEG) on 5 March 2002 for enteral feeding. She developed frequent vomiting of the nutrients administered through the PEG tube 26 months after PEG placement. We tried gastric motility stimulant drugs, but these were ineffec− tive, and on 21 June 2004 we performed a direct percutaneous endoscopic jeju− nostomy (D−PEJ). A one−step button (Bos− ton Scientific, Natick, Massachusetts, USA) was placed approximately 15 cm distal to the ligament of Treitz, according to methods described previously [1]. Seventeen months after the D−PEJ place− ment, she suddenly vomited gastric juic− es and the nutrients administered through the D−PEJ, and this was compli− cated by the development of aspiration pneumonia. A small−caliber endoscope (GIF XP−240; Olympus Optical Co. Ltd., Tokyo, Japan) was inserted through the jejunocutaneous tract, and we found a round, irregular−shaped tumor on the op− posite wall of the fistula (l" Figure 1). A biopsy specimen from the tumor revealed inflammatory granulation tissue infiltrat− ed with neutrophils (l" Figure 2). Adverse events reported to be associated with D−PEJ to date are bleeding, colonic perforation, abdominal wall abscess, jeju− nal volvulus, aspiration, persistent enter− ocutaneous fistulas, peristomal leakage and infection, and jejunal ulcer [2]. This is the first case report of intrajejunal granuloma formation after D−PEJ. Peristo− mal granulation occurs frequently after PEG. Intragastric pseudotumoral gastric mucosa or bumper−related polyps have also been reported previously [3, 4]. These tumors are thought to be caused by re− peated stimulation of the gastric mucosa by the inner bumper after PEG. Histologi− cal examinatin of the tumors usually re− veals hyperplasia of the foveolar epithe− lium of the gastric mucosa, but occasion− ally inflammatory granulation is found [4]. In this case, the top of the bumper was touching the opposite wall of the fis− tula and caused inflammation. Intrajeju− nal granuloma should be noted as a po− tential adverse effect of D−PEJ.