Venting issues.

Introduction: A 65-year-old woman with type 3 intestinal failure secondary to scleroderma of the gut (limited cutaneous sclerosis (centromere positive) and rheumatoid arthritis (anti-cyclic citrullinated peptide (CCP) and rheumatoid factor positive)) on home parenteral nutrition since 2011 underwent a venting PEG replacement in 2015 for intractable vomiting due to gut dysmotility and small bowel bacterial overgrowth, poorly responding to cyclical antibiotics. An endoscopy was undertaken for planned PEG review for consideration of elective replacement (figure 1).Figure 1Initial endoscopy.Based on this endoscopy, her case was discussed at a multidisciplinary team meeting and the anaesthetic risk of laparotomy to remove the PEG was deemed too high (previous endoscopic PEG exchange under sedation had been poorly tolerated due to tube removal through the oesophagus (possibly affected by scleroderma), and necessitated anaesthesia). Therefore, it was decided to insert a new venting PEG endoscopically alongside the previous buried PEG (cut short and clamped) with the plan to remove the old one at a later date.What is shown during the initial endoscopy?What is shown during follow-up endoscopy?

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Authors: Neel Sharma, Rachel Cooney, Sheldon C Cooper