Pneumoperitoneum and PEG Dislodgement Secondary to Noninvasive Ventilation after PEG Tube Placement

Abstract

We present a previously undescribed complication after noninvasive ventilation (NIV) for respiratory failure in a patient who required percutaneous endoscopic gastrostomy (PEG) tube placement for long-term nutrition after a complicated coronary bypass operation. A 54-year-old female diagnosed with unilateral vocal cord paralysis after emergent coronary artery bypass grafting (CABG) underwent an uncomplicated PEG tube placement. She was placed on intermittent NIV because of respiratory failure 24 hours after PEG placement, and NIV was continued for several days. Three days later, she was noted to have pneumoperitoneum on an upright chest X-ray. Abdominal CT scan revealed a large amount of pneumoperitoneum with the PEG tube in the correct position and no extravasation of enteric contrast from the stomach. Tube feeds were held and NIV was discontinued. Nonetheless, six days later, the patient was found on CT scan to have partial displacement of the PEG tube with leakage from the gastrotomy requiring operative repair. This case highlights the vulnerability of PEG tubes to management practices in the early postoperative period. Abdominal distention secondaryto NIV likely caused pressure necrosis of the PEG site with dislodgement of the tube. This case elicits considerations regarding future management practices of patients receiving NIV in the early postoperative period after PEG placement.

Respiratory Failure in Acute Medical Unit

“…Gastric distention can occur, but vomiting and aspiration pneumonia are less likely. Nasogastric tube placement is not recommended for all patients on NIV; however, caution with patients with percutaneous endoscopic gastrostomy as pneumoperitoneum and tube displacement can occur [15]. Serious NIV-related complications, such as barotrauma, are rare compared to invasive mechanical ventilation [16].…”

Rare case of pseudo-pneumoperitoneum as a triad of extensive subcutaneous emphysema and pneumomediastinum as a complication of non-invasive respiratory support

“…BiPap and CPAP were used for respiratory support in all instances of pneumoperitoneum reviewed for this case. 2,[12][13][14][15][16][17] HFNC use has been associated with PMN/SE; however, it is theorized HFNC is a better modality of respiratory support in these patients as it exerts minimal positive end-expiratory pressure (PEEP), decreasing alveolar overdistension and self-inflicted lung injury. 7,9 The positive correlation of higher PEEP with PMN/SE has been observed clinically with patients receiving more aggressive pressure support demonstrating increased complications from NIV.…”

“…3,[8][9][10][11][12] The much rarer phenomenon of spontaneous pneumoperitoneum has been documented in only several cases. 2,[12][13][14][15][16][17] We present a case of a pseudo-pneumoperitoneum associated with non-invasive respiratory support, but uniquely, as part of a triad of pneumomediastinum with extensive subcutaneous emphysema extending circumferentially around the abdomen and down into the scrotum. To our knowledge, this has not been described elsewhere.…”