Transpyloric misplacement and intramural dislocation: two novel complications related to balloon-type G-tubes

**Background:** Percutaneous endoscopic gastrostomy (PEG) is the standard method for providing enteral nutrition access, with a generally low complication profile. Balloon-type G-tubes, placed via the introducer technique, require regular exchanges that are often performed by nursing staff. While complications such as buried bumper syndrome are well recognized, no prior reports have described transpyloric misplacement or intramural dislocation of balloon-type G-tubes. This letter reports two such novel complications.

**Methods:** This is a case report (letter to the editor) describing two patients who experienced unusual complications related to balloon-type G-tube exchange. The author presents the clinical history, endoscopic findings, and management for each case. No systematic review, statistical analysis, or prospective data collection was performed.

**Key Results:** - Patient 1: A frail male patient with advanced diffuse idiopathic skeletal hyperostosis (DISH)-related dysphagia developed worsening enteral nutrition tolerance and abdominal pain after a bedside tube exchange by a specialized nutrition team in a nursing home. Endoscopy revealed transpyloric misplacement of the balloon-type G-tube, likely due to inadvertent duodenal guidewire insertion. The tube was resistant to repositioning by external traction. Endoscopy-directed repositioning was easily performed after balloon deflation and withdrawal into the stomach. Other potential causes (e.g., ulcer disease) were excluded. The author notes this complication may have been avoided by strictly observing distance markings during tube exchange, although the distance between the PEG exit point and the pylorus was short. - Patient 2: A patient with a history of head and neck cancer presented with high-grade abdominal pain after being discharged from a hospital the same day following reinsertion of a balloon-type G-tube using the same PEG stoma (the previous tube had been lost externally during care measures). CT scans showed minor free abdominal and intramural air in the stomach, suggesting tube dislocation. Urgent endoscopy under CO2 insufflation revealed a markedly edematous and hyperemic "pseudotumor" in the antrum, consistent with intramural balloon dislocation. After balloon deflation, the stoma entry site was found in the vicinity, and the tube was repositioned correctly under endoscopic vision, avoiding the need for surgery. The cause remains unclear; incomplete balloon blocking and/or overly aggressive tube retraction during post-endoscopy care are speculated.

**Clinical Implications:** These two cases describe previously unreported complications of balloon-type G-tubes: transpyloric misplacement and intramural dislocation. Both were managed endoscopically without surgical intervention. The author emphasizes that strict adherence to tube exchange protocols and proper tube care are essential to prevent these complications, similar to the approach for more common G-tube-related complications such as buried bumper syndrome. Clinicians should be aware of these potential adverse events when evaluating patients with balloon-type G-tubes who present with abdominal pain or feeding intolerance after tube exchange.