A 78-year-old male was admitted to division of gastroenterology due to melena, abdominal discomfort and fever that had developed 2 days prior. The patient had a medical history of left middle cerebral artery infarction. He had suffered from recurrent aspiration pneumonia and thus underwent PEG tube insertion using Ponsky PEG Kit (Bard Endoscopic Technologies, Billerica, MA, USA) 8 days before admission. At that time, the PEG tube was well-positioned in the gastric lower body lessor curvature without any complication. The body temperature was 37.8°C, the pulse was 88 beats/min, respiration was 22/min, and blood pressure was 160/90 mm Hg. Laboratory results showed the white blood cell count was 23,100/μL, neutrophil 84%, hemoglobin 5.9 g/dL, platelet count 433,000/μL, erythrocyte sedimentation rate 114 mm/hr, and C-reactive protein 8.76 mg/dL. Upper endoscopy was performed to evaluate the cause of melena and showed deep ulceration with exudates surrounding the internal bumper and embedding of the internal bumper into the gastric wall (Fig. 1A). Computed tomography (CT) revealed an ill-defined enhancing lesion with fat infiltration and air bubbles around the gastrostomy track (Fig. 1B). The patient was diagnosed with upper gastrointestinal bleeding and abdominal abscess due to acute BBS. Therefore, we immediately removed the buried PEG tube with external traction using minimal exertion and administered broad spectrum antibiotics to allow the original site to heal before attempting replacement of the PEG tube. A high-dose proton pump inhibitor was also used to decrease gastric secretions and prevent rebleeding. A Foley catheter was inserted 3 days after PEG tube removal to maintain the old track site. The abscess around the track was nearly resolved 27 days after PEG tube removal (Fig. 1C). The new PEG tube was reinserted through the old track after removal of the Foley catheter under endoscopic guidance (Fig. 1D).

A 67-year-old male developed double hemiplegia, dysphagia and aspiration of food during meals as a result of a multiple territory infarction. Therefore using Ponsky PEG Kit (Bard Endoscopic Technologies), a PEG tube was placed on the mid-body greater curvature for enteral feeding. No complication related to the procedure developed at that time. Eleven days post-procedure, the patient presented to our hospital complaining of abdominal pain and an inability to infuse food through the tube. With the exception of a 38.0°C fever, his vital signs and laboratory tests were unremarkable. The patient subsequently underwent a CT scan of the abdomen that revealed the internal button of the gastrostomy tube in the abdominal wall layer without any evidence of abscess or peritonitis. Upper endoscopy also showed an ulcer-like mucosal defect in the previous internal opening site of the PEG tube (Fig. 2A). The patient was diagnosed with acute BBS without abscess. The old PEG tube was removed manually with external traction using minimal exertion and the zig-zag guidewire was inserted through the previous track under fluoroscopic guidance (Fig. 2B). A balloon-type gastrostomy tube was successfully placed over the guidewire, with the guidewire tightly fixed using grasping forceps (Fig. 2C, D). The patient was given antibiotic treatment for 3 days after the procedure. No complication developed related to the procedure. Subsequently, his wound care was completed and he started enteral feeding via the PEG tube during hospitalization; he was discharged to the nursing home in stable condition.