Supplementary Material for: Life-threatening Upper Gastrointestinal Bleeding Following Percutaneous Endoscopic Gastrostomy Tube Removal Under Traction: A Case Report

Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes are commonly used to facilitate long-term enteral nutrition. Selected PEG tubes may be appropriately removed without endoscopic guidance via gentle traction, which is seldom associated with major bleeding sequelae. Rare reports of major upper gastrointestinal (GI) hemorrhage following PEG tube removal have been managed using Foley catheter balloon tamponade or endoscopic over-the-scope clipping. Prompt reinsertion of a PEG tube may also be considered. Case presentation: We present the case of a multi-morbid 73-year-old female who experienced life-threatening hemodynamically unstable upper GI bleeding following traction PEG tube removal which proved refractory to standard endoscopic measures of adrenaline injection and hemostatic clipping, as well as rotational thromboelastometry-guided correction of consumptive coagulopathy. There was no suitable target for angioembolization. Ultimately, in the context of continued hemodynamically unstable GI bleeding, definitive surgical hemostasis – a mode of intervention not frequently reported for bleeding of this nature – was achieved during emergency laparotomy via complete excision of the PEG tract and wedge excision of the involved stomach wall. Conclusion: Life-threatening hemodynamically unstable GI bleeding rarely complicates traction PEG tube removal. In elderly patients with multiple co-morbidities, PEG tract bleeding refractory to standard endotherapy and not targetable by angioembolization can be safely and effectively managed with timely surgical intervention.