A 74-year-old man with a history of cerebral infarction was admitted with watery diarrhea that had lasted for 1 month. PEG had been performed 9 months prior to this admission. The patient's condition had been stable for 8 months after PEG. Vital signs and laboratory results upon admission were as follows: blood pressure, 80/40 mmHg; body temperature, 36.8℃; white blood cell count, 18,300/µL; hemoglobin level, 13.2 g/dL; BUN level, 10.3 mg/dL; creatinine level, 0.9 mg/dL; urine white blood cell count, high. His septic condition improved after adequate hydration and the administration of broad-spectrum antibiotics. However, the postprandial watery diarrhea persisted. On the 12th day of hospitalization, an upper endoscopy revealed a gastrocolic fistula and the internal bumper of the PEG tube was not seen (Fig. 1A). The feeding tube was withdrawn after the upper endoscopy. On the same day, a colonoscopy also revealed a gastrocolic fistula in the transverse colon (Fig. 1B). Several metal clips were applied to seal the gastrocolic fistula opening (Fig. 1C). Abdominal CT performed before upper endoscopy showed that the bumper of the feeding tube had migrated into the colonic lumen (Fig. 2A) and revealed a fistula tract between the stomach and colon (Fig. 2B). In a radiologic study using gastrografin administered through the nasogastric tube 1 week later, there was no leakage of dye (Fig. 3). The patient was discharged with a nasogastric tube for feeding after the external opening of the gastrocolocutaneous fistula was closed. The patient has been alive in a nursing home for 3 months after discharge from the hospital.

A 77-year-old man with a history of alcoholic dementia and intracerebral hemorrhage was referred by a nursing home to undergo an exchange of feeding tubes because his tube had suddenly loosened 3 days previously. He had undergone a PEG procedure 3 times and a simple exchange of PEG tubes twice. The first PEG procedure was performed 33 months earlier for enteral feeding. The second PEG procedure was performed 2 weeks after the first because the patient had forcibly pulled out the initial feeding tube. The second PEG procedure had to be newly done because the tract of the first PEG site was obstructed shortly. The site of the second PEG was close by the first PEG site. The patient's condition was stable for 27 months after the second PEG procedure was done. The third PEG procedure was performed 6 months prior to this consultation owing to buried-bumper syndrome. At that time, the patient presented with a loosened tube and abdominal pain. Because an upper endoscopy revealed that the feeding tube bumper was buried in the gastric wall (Fig. 4A), the feeding tube was removed. The previous fistula tract required 4 days to close completely. Subsequently, a new gastrostomy was performed near the previous PEG site before discharge. The patient's condition had been stable for 6 months after the third PEG. Upon admission to our hospital, the patient's blood pressure was 90/60 mmHg and body temperature was 36.1℃. The blood test results were as follows: hemoglobin level, 3.7 g/dL; BUN level, 108.2 mg/dL; creatinine level, 5.5 mg/dL; estimated glomerular filtration rate, 10.7 mL/min/1.73 m²; and CRP, 229.99 mg/dL. An upper endoscopy revealed that the bumper of the feeding tube was deeply buried within the gastric wall, forming a hole (Fig. 4B). A large space was observed when the scope was advanced into the hole, and brownish material was attached to the bumper (Fig. 4C). These findings suggested gastric wall perforation resulting from a deeply buried bumper. The feeding tube was exchanged to seal the gastric wall opening, and the bumper of the tube was positioned in the gastric cavity. The patient was admitted to the intensive care unit. Because peritonitis and aspiration pneumonia caused a septic condition with acute kidney injury, medical therapies including hydration, blood transfusion, continuous renal replacement therapy, and broad-spectrum antibiotics were applied. In consideration of the patient's condition, medical treatment, including total parenteral nutrition, was continued rather than using a surgical option. The feeding tube was withdrawn when pus discharged from the gastrostomy site on the 10th day of hospitalization. The patient's condition improved for a while, and the external opening of the colocutaneous fistula was nearly closed 3 weeks after admission. According to his family's request to insert a feeding tube through the gastrostomy tract, an upper endoscopy was performed again. The gastric wall opening was still unhealed. When the scope was advanced into the opening, the lumen of the transverse colon and a bluish liver shadow were identified (Fig. 4D). The diagnosis of a gastrocolocutaneous fistula was confirmed at that time. The patient died of multiple organ failure caused by pneumonia aggravation 1 week later.