Background:
Percutaneous endoscopic gastrostomy (PEG) is an effective and safe mode of enteral nutrition for patients needing chronic enteric nutritional support. Exchanging PEG tubes may result in complications due to inexperience as well as due to lack of protocol.
Case report:
We encountered a 73 year-old female with unnoticed, accidently detached portion of the internal bumper of a PEG tube in the gastric lumen after a challenging gastrostomy tube exchange.
Conclusions:
This case report discusses the complications associated with gastrostomy tube exchange and proposes a planned protocol for successful gastrostomy tube exchange.