2172 Importance of Chest and Abdominal Imaging Before Placing a PEG Tube

INTRODUCTION: Percutaneous Endoscopic Gastrostomy (PEG) tube placements are a common procedure these days and are often seen as a safer and cheaper alternative to surgical gastrostomy tube placement with increasing rate of deployment over the years. They are however dependent on several factors including anatomic presentation and availability of resources. CASE DESCRIPTION/METHODS: A 75 year old lady with multiple medical conditions who came to hospital from nursing home after she was noted to have failure to thrive and dysphagia. After admission GI was consulted for PEG placement. Initial physical exam during the consult revealed benign abdomen – non tender, non-distended with present bowel sounds without deformities. On imaging however, the chest x-ray (Figure 1) shows the presence of the patient’s stomach and small bowel within the patient’s chest cavity due to a large hiatal hernia, as well as pleural effusion with left lower lobe infiltrate. CT chest (Figures 2 and 3) was done to confirm CXR findings and revealed a large retro-cardiac hernia containing multiple loops of large bowel, small bowl and stomach with segmental left lung subluxation. Patient was treated with antibiotics for aspiration pneumonia; however, patient was deemed to be a poor candidate for PEG placement due to anatomy as well as a poor candidate for hernia repair given advanced age and comorbid medical conditions. Given poor prognosis, goals of care were discussed with patient’s family who opted for a palliative approach and patient was eventually discharged to a hospice care facility. DISCUSSION: While PEG placement is becoming a rapidly prevalent procedure, there is no guideline regarding risk stratification of placement with use of imaging. In our experience, imaging should be a main stay of initial investigation alongside history and physical exam given that anatomic variations/changes may not always be apparent on history and physical exam alone.