Sonographic diagnosis of transhepatic placement of a percutaneous endoscopic gastrostomy (PEG) tube.

a percutaneous endoscopic gastrostomy (PEG) tube A 44-year-old patient with cachexia and insufficient oral intake due to hypopharyngeal carcinoma underwent percutaneous endoscopic gastrostomy (PEG) placement with the pull technique, which is a common option for the treatment of dysphagia [1]. Transillumination and finger pressure revealed a safe puncture site at the anterior gastric wall, and the PEG tube was placed without complications at the time of the intervention. Initial tube feeding went properly, and the patient was discharged the next day. After 4 days, the patient was readmitted with progressive epigastric pain, which increased during tube feeding. An elevated C-reactive protein level (43ng/mL) and leukocyte count (14.9×109/L) were observed, although the PEG site showed no signs of infection. Transabdominal ultrasound with a convex transducer revealed the presence of hepatomegaly and perihepatic ascites (●" Fig.1), until then unsuspected, raising the suspicion of PEG tube penetration through the lateral left lobe of the liver. This was confirmed with the use of a high resolution linear array transducer (●" Fig.2,●" Video 1). The PEG tube was removed, and the gastric insertion site was occluded with metal clips to prevent gastric leakage (●" Fig.3). Analgesic treatment and calculated antibiotic therapy were administered for 5 days. The markers of inflammation decreased in response to this therapy, and the initial symptoms disappeared. After 1 week, a new PEG tube was placed to the left of the initial site without any subsequent complications. PEG is generally considered a safe procedure, and serious complications are rare [2–4]. However, this case underscores the risk for liver injury due to hepatomegaly not apparent on physical examiFig.1 Ultrasound of the liver reveals the following: a hepatomegaly (craniocaudal diameter in the midclavicular line of 176mm); b moderate perihepatic ascites.