Early Pneumoperitoneum After Percutaneous Endoscopic Gastrostomy in Intensive Care Patients: Sign of Possible Bowel Injury

Abstract

• Background Although percutaneous endoscopic gastrostomy may be complicated by iatrogenic bowel injury, most clinicians consider a small pneumoperitoneum on radiographs obtained after the procedure a benign finding of little clinical consequence. The possibility of a relationship between findings of early pneumoperitoneum after percutaneous endoscopic gastrostomy and subsequent iatrogenic bowel injury was examined. • Methods Charts of 85 patients in a surgical intensive care unit who had undergone percutaneous endoscopic gastrostomy between 2000 and 2005 were retrospectively reviewed. All patients had a follow-up upright chest radiograph obtained after percutaneous endoscopic gastrostomy. The charts of 4 patients with radiographs that showed early pneumoperitoneum were reviewed. • Results Findings were clinically significant in 1 of the 4 patients. That patient had a perforated transverse colon that required surgical repair. The other 3 patients had no complications. • Conclusion Pneumoperitoneum after percutaneous endoscopic gastrostomy may be a sign of possible bowel injury and requires further evaluation. It should not be dismissed as benign. Obtaining a chest radiograph after a patient has undergone percutaneous endoscopic gastrostomy is essential.

Reappraisal of Pneumoperitoneum After Percutaneous Endoscopic Gastrostomy

“…Another study also reported that a moderate or large pneumoperitoneum usually persists after 72 hours. 11 Given our results and previous reports, 2 12 13 14 complicated pneumoperitoneum cannot be predicted by the time to resolution and is unlikely to occur in patients with a small pneumoperitoneum.…”

“…The incidence estimates for pneumoperitoneum in the literature range from 4.7%-55.6%. 8 13 Differences in methodology, expertise with the PEG technique, or endoscopic equipment explain some of the variability in the incidence. An imaging study after insertion of PEG is usually performed to assess complications such as pneumonia or fever.…”

“… 4 10 11 In a study of PEG in intensive care patients, 1 in 4 patients who had pneumoperitoneum had neither clinically significant signs nor signs of peritoneal irritation. 13 The primary indication of complicated pneumoperitoneum is a large pneumoperitoneum that does not resolve within 72 hours. In our study, the range of time to resolution of free air was 2-18 days.…”

“… 4 5 6 7 8 Pneumoperitoneum is an infrequent finding following insertion of PEG, 4 8 9 10 and usually has a benign and self-limiting clinical course, 4 10 11 while complicated pneumoperitoneum, such as bowel injury after PEG insertion, has been reported rarely. 2 12 13 14 Thus, a reappraisal of pneumoperitoneum after PEG insertion is needed. In this study, we investigated the incidence and clinical significance of free air after PEG was performed at our institution over a 6-year period and provide a review of the English-language literature describing pneumoperitoneum after PEG tube placement.…”

Percutaneous Gastrostomy Tube Placement: Recognizing When Things Go Wrong

“…Some physicians have suggested that even without peritoneal signs and symptoms, iatrogenic bowel injury may be present and all pneumoperitoneum requires further diagnostic studies. 30 This is particularly true of ICU patients and those with altered mental status where the usual clinical symptoms of peritonitis can be masked. 31 If signs of peritonitis or infection are present, further evaluation is necessary.…”