Retrograde coiled spring jejunal intussusception in an infant following gastrostomy by Foley catheter: report of a case | BMC Gastroenterology

Foley catheters, which were designed for urinary drainage about a century ago, have a wide range of indications in the gastrointestinal system [7]. However, using a Foley catheter as a feeding gastrostomy catheter can cause secondary retrograde coil spring intussusception. The exact mechanisms of feeding tube-induced anterograde and retrograde intussusceptions are unknown and may be distinct for each type. In anterograde intussusception, the feeding catheter irritates the bowel and causes thickening, which then serves as a lead stitch, or the balloon acts as a lead stitch. In rarer cases of retrograde intussusception, attempts to retract to retrieve a migrated catheter, similar to a fishing rod, may result in intussusception from the distal bowel into the proximal bowel and cause retrograde intussusception, as in our patient. [3]. Although the etiology of intussusception in the pediatric population is primarily idiopathic, secondary intussusception can occur due to a variety of etiological factors. [12, 13]. The inclusion of feeding catheter migration as a rare cause of secondary intussusception in children will be helpful for early diagnosis.

Studies of anterograde and retrograde intussusception related to feeding catheters are primarily presented as case reports. The time interval between tube placement and intussusception differs for each case, ranging from days to years and there is no specific age group at risk. Varying lengths of intussusceptions involving the stomach, duodenum, jejunum, and ileum due to initially inserted or replaced feeding catheters have been reported. Different types/brands of feeding tubes, including PEGs (percutaneous endoscopic gastrostomy) and Pezzer catheters, via open or endoscopic approaches have also been reported. Given the limited number of patients in the literature, it is not possible to identify etiological or risk factors for intussusception. [3, 13,14,15,16,17,18,19,20,21].

Three adult patients with varying lengths of retrograde intussusceptions involving the stomach, duodenum, and jejunum have been published as case reports [16,17,18]. Our patient is the youngest case of retrograde intussusception reported in the literature.

Intussusception due to a feeding tube is diagnosed quite late despite the results of physical examination and imaging tests because the results of classic intussusception are not physically observed and catheter-related intussusceptions are more stable clinically than classic intussusception, with the exception of bilious vomiting [15]. Unlike features of ileus, the abdomen may be scaphoid [3] and soft with normal bowel sounds [16]. The contents of the feeding tube drainage can also be a diagnostic tool [13]. The diagnosis of intussusception can be made with water-soluble contrast studies, which may show a coiled-spring appearance [15, 16]with air when administered through the fluoroscopy feeding tube [20]or by abdominal ultrasound, (US) [19]contrast CT scan [13]or upper endoscopy [17]; a diagnosis can also be made post mortem [14].

Various approaches can be used to reduce intussusception and assess intestinal viability. Some patients are first evaluated/diagnosed by endoscopy or laparoscopy and then converted to open surgery [13, 18]. Surgical management techniques include manual reduction [13]only repairing intestinal perforations after reduction [16]or resection and anastomosis of the affected segment [18, 19]. Other treatment options for patients with feeding tube-related intussusception who are in better health or at significant surgical risk include close observation after feeding tube removal or replacement [17, 21]. However, these options are not always sufficient, especially for small infants with neurological and comorbid conditions, as there is a possibility of ischemic bowel in the intussusception. [19]. Further investigations to exclude intussusception are warranted.

We would like to point out that several minute perforations are specific to several consecutive intussusceptions. Ragunath et al. [16] detected three distinct tiny perforations, whereas we detected seven. Especially in the setting of multiple consecutive intussusceptions, once the bowel is reduced, each intussuscepted segment should be evaluated for tiny perforations. Since all infants with feeding tubes have one or more serious illnesses that affect oral feeding, a difficult diagnosis and postoperative period should be expected. [13, 19].

Shortening of the outer part of the catheter may be an early indication of migration even before clinical signs of small bowel obstruction can be found [16]. After the operation, the mother of the patient in our case said that the outer part of the catheter had appeared shorter in the last few days and she tried to put it back in place. If the mother knew the risk of displacement of the gastrostomy tube, early warning would probably have reduced the severity of consecutive multiple intussusceptions. Caregiver education and provision of written and verbal instructions well in advance of discharge is important to avoid complications from catheter migration, even in those with an external anchor device.

In a study exploring the ideal gestational age for feeding tube placement for reliable post-discharge nutrition, it was found that patients at

Placement of gastrostomy devices has increased over time, and a Foley catheter is placed in a patient at least once during initial insertion or replacement [4, 22]. Foley catheter complications therefore increase with the number of tube-fed patients. Although minor and major complications occur with all types of catheters [2]the use of Foley catheters for enteral nutrition can lead to many problems in terms of the use of unlicensed products and due to professional and ethical responsibilities [4]. Additionally, there are no evidence-based studies of the use of Foley catheters as gastrostomy tubes. [7]. The reasons Foley catheters are used include their low cost, small size, which is suitable for infants, ease of application, and clinicians’ familiarity with Foley catheters. In emergency situations, such as with our patient, a Foley catheter can be used to ensure the stoma is patent and patients have access to fluids, nutrition, and medications. [4]. However, to eliminate the risk of tube migration, an external fixation device should be applied to the Foley catheter. Proper attachment of these tubes to the abdominal wall is necessary not only to prevent dislodgement, but also to prevent internal migration. External length should be recorded during tube placement to help identify instances of displacement [11, 17, 22]. Other preventative options include gastrostomy placed away from the pylorus [14]. If the catheter is no longer in use, it should be removed to prevent migration [16]. Caregivers should regularly inspect the gastrostomy site and the outer length of the tube [11].

In conclusion, patients with ineffective feeding catheters, respiratory tract infections, and vomiting complaints should be evaluated for bowel obstruction. Awareness of the migration of the feeding catheter into the intestine and its potential to cause intussusception facilitates early diagnosis and treatment. The use of Foley catheters is a temporary measure to avoid gastrostomy closure pending proper replacement of gastrostomy tubes, and they are not recommended as a long-term replacement feeding tube. Therefore, it should be replaced as soon as a gastrostomy tube is available.