Peritoneal leakage of gastric contents, a rare complication of percutaneous endoscopic gastrostomy.

Background: A 94-year-old man underwent a routine percutaneous endoscopic gastrostomy but 7 days later developed abdominal pain and died of a previously unreported late complication. Methods: A case report of the main clinical and pathological findings and a brief discussion of the significance of the case. Results: Postmortem examination revealed a chemical peritonitis due to leakage of 2.8 L of formula into the peritoneal cavity through an enlarged gastrostomy hole around a correctly positioned tube. Conclusion: This is a previously unreported complication that occurred because of repeated pulling on the tube by a confused patient, causing a loss of the usual apposition of the gastric and the anterior abdominal walls. The importance of the case is to emphasize that late, even fatal, complications can occur until a permanent fibrous tract has been formed between the skin and the gastric wall.