Gastrostomy tube dislodgement is a well known complication in patients with percutaneous endoscopic gastrostomy (PEG). Tube migration into the duodenum was less frequently reported. When the migrated tube has an inflatable internal balloon, as in replaced PEG-tubes or in Foley catheters, the balloon may obstacle gastric emptying and disturb biliary and pancreatic juice flow at the level of the ampulla of Vater. The paper describes the case of a child with cerebral palsy whose balloon PEG-tube repeatedly migrated into the duodenum causing a mild pancreatic disease with increased amylase and lipase blood levels. Moreover, the few cases of pancreatitis due to migration of a gastrostomy tube reported in the literature are briefly reviewed.
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