Percutaneous endoscopic gastrostomy (PEG) is a common practice usually offered to patients who are unable to tolerate or swallow oral feed and require long-term nutrition. We present a case of early pneumoperitoneum after a PEG placement due to colonic perforation. The patient was severely malnourished and had a medical history of brain injury, cerebrovascular accident cerebrovascular accident (CVA) and bilateral below knee amputations from a bomb blast 13 years ago. The PEG tube was placed under sedation. On the first postoperative day, the patient had a subtle pneumoperitoneum that was considered secondary to the procedure. On the third postoperative day, the patient became tachycardiac with abdominal distension. A CT scan showed the PEG tube traversing through the transverse colon. The patient underwent a laparotomy and repair of colonic injury and made an uneventful recovery.