This case report describes an extremely rare complication that occurred when an 83-year-old man had a feeding tube replaced. Instead of staying in his stomach where it belonged, the new tube accidentally poked holes into his colon (large intestine), creating three separate leaks. Doctors discovered this problem when the patient developed severe belly pain and diarrhea the day after the procedure. Emergency surgery was needed to fix the damage, but the patient recovered well. While feeding tubes are generally safe and helpful for people who can’t swallow normally, this case reminds doctors to carefully check that tubes are placed correctly and to act quickly if problems develop.

The Quick Take

  • What they studied: A single patient who developed a serious complication from a feeding tube replacement procedure
  • Who participated: One 83-year-old man with Parkinson’s disease who had difficulty swallowing and needed a feeding tube for nutrition
  • Key finding: The replacement feeding tube accidentally created three holes between the patient’s stomach and colon instead of staying in the stomach, which is extremely rare and had never been reported before
  • What it means for you: If you or a loved one needs a feeding tube, know that serious complications are very uncommon, but doctors should always verify the tube is in the correct position right after placement. If you experience severe abdominal pain or unusual diarrhea after a feeding tube procedure, seek emergency care immediately.

The Research Details

This is a case report, which means doctors are sharing the story of one patient’s unusual medical experience. A case report is the simplest type of medical study—it’s like a detailed medical story rather than a research experiment. The doctors described what happened to this one patient, step-by-step, including his medical history, the procedure he had, what went wrong, and how they fixed it. They reviewed his medical records, imaging scans, and surgical findings to piece together the complete picture of what happened.

Case reports are important because they alert the medical community to rare complications that might not show up in larger studies. When something has never been reported before (like this triple fistula), doctors need to know about it so they can recognize similar problems in their own patients. This helps improve safety and patient care.

As a case report of a single patient, this study cannot prove that something will happen to many people—it just documents what happened to one person. However, the detailed medical documentation, imaging evidence, and surgical findings make this a well-documented case. The fact that this is the first reported case of this specific complication makes it medically significant, even though it involves only one patient.

What the Results Show

An 83-year-old man with Parkinson’s disease initially received a feeding tube (called a PEG tube) placed through his skin directly into his stomach. This tube worked well for one year. When the tube became blocked, doctors tried to replace it using a minimally invasive technique (guided by X-rays rather than surgery). However, the new tube was accidentally placed into his colon instead of his stomach. The next day, the patient developed severe abdominal pain and diarrhea. Imaging scans showed the tube was in the wrong place. During emergency surgery, doctors discovered something never before reported: the tube had created three separate holes or fistulas—connections between the stomach and colon that shouldn’t exist. Two of these were in the transverse colon (the upper part of the large intestine) and one was in the sigmoid colon (the lower part).

The surgical team successfully repaired the damage by removing the affected section of colon, carefully closing the stomach with multiple layers of stitches, and creating a new surgical feeding tube. The patient recovered without additional complications and was discharged from the hospital eight days after surgery. This successful outcome demonstrates that even rare and serious complications can be managed effectively with prompt recognition and appropriate surgical intervention.

Feeding tubes (PEG tubes) have been used safely for decades and are considered a standard, reliable procedure for people who cannot swallow. Complications do occur but are generally uncommon and usually minor. Tube misplacement is a known risk, but creating three separate holes between the stomach and colon has never been documented before in medical literature. This case represents a previously unknown possible complication, making it medically significant despite its extreme rarity.

This is a single case report, so we cannot determine how often this complication might occur or predict who is at highest risk. We cannot draw conclusions about feeding tube safety in general based on one unusual case. The patient was 83 years old with Parkinson’s disease, so results may not apply to younger patients or those with different medical conditions. Additionally, this complication occurred during a radiological (X-ray guided) replacement rather than the original surgical placement, so the risk factors may be different for initial tube placement.

The Bottom Line

For patients needing feeding tubes: Feeding tubes remain a safe and effective way to provide nutrition for people who cannot swallow normally. The benefits far outweigh the risks for appropriate patients. However, always ensure that tube placement is confirmed with imaging before using it, and report any severe abdominal pain, fever, or unusual diarrhea immediately to your doctor. For healthcare providers: Always verify correct tube placement with imaging before the patient uses the tube, and maintain a high index of suspicion for tube misplacement if patients develop acute abdominal symptoms after tube placement or replacement.

This case is most relevant to: (1) Patients with swallowing difficulties who need feeding tubes, (2) Family members of such patients, (3) Healthcare providers who place or manage feeding tubes, and (4) Hospital emergency departments. People considering feeding tubes should not be discouraged by this case, as serious complications remain very rare. However, awareness of potential complications helps ensure prompt recognition and treatment if problems occur.

In this case, the complication developed within 24 hours of the tube replacement procedure. Most feeding tube complications, if they occur, develop within the first few days after placement. After successful surgical repair, recovery typically takes 1-2 weeks, as demonstrated by this patient’s eight-day hospital stay.

Want to Apply This Research?

  • If you have a feeding tube, use the app to log daily symptoms: abdominal pain level (0-10 scale), bowel movement frequency and consistency, fever or chills, and tube function (any leakage or blockage). Set daily reminders to check the tube insertion site for redness, swelling, or drainage.
  • Create a symptom alert system: if you experience severe abdominal pain (7+/10), fever over 101°F, persistent diarrhea, or signs of infection at the tube site, immediately log it in the app and seek emergency care. Share your feeding tube history and this app log with any new healthcare provider.
  • Establish a weekly review routine: every Sunday, review your symptom log from the past week. Look for patterns in pain, bowel movements, or other issues. Share monthly summaries with your healthcare team during regular check-ups. If you’re having a tube replacement procedure, photograph the confirmation imaging and keep it in your health records.

This case report describes an extremely rare complication of feeding tube placement. Feeding tubes remain a safe and effective treatment for people who cannot swallow normally. This single case should not discourage patients from getting a feeding tube if medically recommended. However, all medical procedures carry some risk. Always discuss the benefits and risks of feeding tube placement with your doctor. If you have a feeding tube and develop severe abdominal pain, fever, persistent diarrhea, or signs of infection, seek emergency medical care immediately. This information is educational and should not replace professional medical advice from your healthcare provider.