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Percutaneous Endoscopic Jejunostomy Tube Placement for Treatment of Severe Hyperemesis Gravidarum in Pregnancy

Hyperemesis gravidarum is a common disease. Most patients are effectively treated with conservative measures, but gastric feeding and, rarely, post-pyloric feeding can be necessary. A 27-year-old woman, G3P2002, with a history of refractory hyperemesis in previous pregnancies, required placement of a nasojejunal tube but was removed due to an oropharyngeal ulcer. Endoscopic placement of a percutaneous endoscopic transgastric-jejunostomy (PEG-J) tube caused resolution of her symptoms. Twelve days after placement, the distal tube became dislodged and was endoscopically replaced with hemoclip anchoring in the jejunum. PEG-J tube placement is a safe and effective option for nutritional support in refractory hyperemesis gravidarum.


Introduction
Hyperemesis gravidarum (HG) occurs in up to 2% of preg nancies nationwide and up to 20% can expect symptoms to persist throughout the pregnancy, often leading to severe complications. 1 Clinically, patients develop nausea and vomiting, associ ated hypovolemia, and ultimately maternal and fetal compro mise. Persistent HG can lead to maternal complications such as dehydration, metabolic abnormalities, weight loss, muscle weakness, Boerhaave's syndrome, and encephalopathy due to vitamin deficiencies. 2 The pathophysiology is complex and multifactorial; however, it can be summarized as being a com bination of hormonal changes, hepatic dysfunction, metabolic derangements, lipid alterations, and psychological/socio cultural factors. 3 Symptom management and initial aggressive intravenous fluid resuscitation is paramount. However, medi cal management can be inadequate in controlling severe symptoms, occasionally requiring enteral feeding either via nasoenteric or percutaneous enteric tube feeds. We present a rare case of a pregnant female with severe HG that ultimately required a percutaneous endoscopic transgastricjejunostomy (PEGJ) due to the necessity of postpyloric feeding.

Case Report
A 27yearold female, G3P2002, with a past medical history of HG in all prior pregnancies presented complaining of persistent nausea and worsening pain in the posterior oro pharynx. The patient had a nasojejunal tube (NJT) placed with lead shielding of the fetus 8 weeks prior when she was 6 weeks pregnant ( Figure 1). The NJT was placed because the patient had persistent HG that was not adequately man aged with medications. The patient either had side effects or found no relief from ondansetron, metoclopramide, pro chlorperazine, ginger, diphenhydramine, meclizine, or vita min B 6 /dicyclomine. She was having at least 30 episodes of emesis daily and was losing weight. The NJT could no lon ger be continued due to a posterior oropharyngeal ulcer and the discussion of a percutaneous endoscopic gastrostomy (PEG) tube versus PEGJ was explored. Due to persistent nausea and vomiting, bypassing intragastric feeding by placement of a PEGJ tube was determined to be the best option by the obstetric and gastroenterology team. The patient was reassured that propofol, an anesthetic agent with out risks of fetal compromise, would be chosen and that fetal heart tones would be monitored closely for proof of viability. Upper endoscopy revealed normal esophagus and stomach. A 24Fr PEG was placed, and a 12Fr jejunostomy catheter was passed through the PEG into the jejunum ( Figure 2). The largecaliber catheters were chosen to reduce the risk of jeju nostomy tube occlusion. In the recovery room, the patient experienced nausea with multiple dry heaves. The patient was discharged on postprocedure day 4 after her symptoms subsided. Unfortunately, she returned as an outpatient 12 days later with worsening nausea and vomiting. Abdominal radiograph revealed retrograde migration of the jejunal por tion of the tube in the distal stomach ( Figure 3).
The patient underwent a repeat upper endoscopy, and PEGJ dislodgement was confirmed. The PEGJ was removed under endoscopic vision with help of a wire. A mea surement device was used to determine the size of lowpro file PEGJ required. An externally removable 22Fr AVANOS MICKEY lowprofile PEGJ tube was placed using the existing gastrostomy stoma. Proper position of the tube was confirmed by relook endoscopy, the distal tip was secured to the jejunal wall with 3 Boston Scientific Resolution hemo clips (Figure 4 and 5). The patient was subsequently asymp tomatic for the following 18 weeks of pregnancy, and the PEGJ was removed with manual traction at bedside on post partum day 1 without any complications. There were no identifiable findings of fetal malnutrition.

Discussion
Recent literature discussing refractory HG cases requiring PEGJ tube placement is scarce. The first case of PEGJ tube placement for enteral feeding in the setting of refractory HG was described in 1997. 4 Another report soon followed of 2 cases performed at the same institution and then a subse quent case series analyzing 5 patients from 1998 to 2005. 5,6 All of which deemed the procedure a safe and effective    advanced treatment for refractory HG. Our patient developed severe, refractory HG that required multiple procedures to adequately control her emesis and provide nutritional sup port. Intravenous antiemetics and NJT placement were inef fective, which led to significant weight loss and dehydration. Out of concern for fetal and maternal nutritional deficien cies, PEGJ placement was the most appropriate and least invasive intervention. After initial PEGJ tube placement, she had ongoing nausea and vomiting, presumably from PEGJ migration, but other causes such as adverse effects from propofol must be considered. There is no evidence to suggest that HG patients develop worsening nausea and vomiting after propofol administration, but the literature is limited to a handful of case studies describing propofol as being well tolerated in HG patients. 7 Furthermore, there are data to suggest that refractory HG patients may have persis tent symptoms due to Helicobacter pylori infection, which was not tested in this patient. 8 Complications of tube dis lodgement are attributed to the dynamic maternal/fetal anat omy throughout pregnancy in addition to the increased intragastric pressure during vomiting and retching. One ret rospective study analyzed tube migration after using hemo clips in PEGJ placement and found that only 7% experienced tube migration. 9,10 There is substantial evidence in the litera ture that attaching a nonabsorbable (eg, nylon) loop at the end of the Jtube, and clipping it to the surrounding mucosa with an overthescope clip is a great way to prevent tube migration. 9 Perhaps placing hemoclips during the initial pro cedure would have prevented the need for a second proce dure. The lowprofile PEGJ has been shown to have fewer tube dislodgement complications as well as shorter duration of hospital stays in the pediatric population. 11 More studies need to be performed in the adult population. The disadvan tages to lowprofile PEGJ tube placement are that there are lower reported success rates as defined as increased risk of infection and peristomal leakage, which our patient did not have. 12 Alternative management options include parenteral nutrition, which has been found to have the highest compli cation rates. 13 These complications are well characterized and widely recognized, but include catheterassociated infec tions, liver disease, gallbladder dysmotility, intrahepatic cholestasis, and metabolic abnormalities. In conclusion, this case highlights the indication for a PEGJ feeding tube, reviews potential complications of the procedure in preg nancy, but, most important, demonstrates how jejunostomy feeding tubes can be placed safely endoscopically by gastro enterologists and is well tolerated by the mother and fetus.

Authors' Note
This abstract has been presented at the following conferences: (1) ACG Annual Scientific Meeting 2019; San Antonio, TX; October 2019.

Author Contributions
David Kruchko: Primary author; image acquisition. Natasha Shah: Writer of manuscript, image acquisition. Charles Broy: Reviewer of manuscript. Dean Silas: Primary endoscopist; reviewed/edited manuscript.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, author ship, and/or publication of this article.

Ethics Approval
Our institution does not require ethical approval for reporting indi vidual cases or case series.

Informed Consent
Verbal informed consent was obtained from the patient(s) for their anonymized information to be published in this article.