The Incidence and Clinical Significance of Pneumoperitoneum after Percutaneous Endoscopic Gastrostomy: A Review of 722 Cases

Abstract

Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice for establishing enteral access in patients unable to take oral feedings. Serious complications are rare; however, misplaced PEGs and PEG/ Jejunums can lead to hollow viscus injuries with intra-abdominal contamination and subsequent peritonitis, septicemia, and death. The presence of free intra-abdominal air is a reliable indicator of a perforated viscus and often points to a surgical emergency; however, in the case of PEGs, pneumoperitoneum without a perforated viscus, or “benign pneumoperitoneum” creates a diagnostic dilemma. To determine the incidence and clinical significance of pneumoperitoneum after PEG or PEG/Jejunum (J) we reviewed the records of 722 patients who underwent these procedures at our institution. Of 39 patients found to have free air after PEG/PEG/J placement, 33 (85%) had “benign pneumoperitoneum” and were discharged without complication or surgical intervention. Of the six patients with serious complications related to their procedure, five (83%) had clinical signs of intra-abdominal complications (peritonitis) that helped guide their management. Of these six patients, the two receiving abdominal radiographs instead of abdominal CT scanning had a 50 per cent negative laparotomy rate. We present an algorithm for the management of patients found to have pneumoperitoneum after PEG or PEG/J placement.

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.…”

“…Percutaneous endoscopic gastrostomy (PEG) was first described in 1980 by Gauderer et al 1 Since then, PEG has become the method of choice for providing enteral access and nutritional support to patients who are unable to take oral feedings. 2 3 Complications occur after PEG placement, including skin-site infection, acute hemorrhage, hematoma, aspiration, and perforation. 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.…”

“… 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.…”

Experiences of Percutaneous Endoscopic Gastrostomy in our Neurology Intensive Care Unit Patients

“…Despite the general safety of PEG, procedural or postprocedural complications may rarely develop (20,21). The main complications associated with the procedure include bleeding into the abdominal wall or intraperitoneal space.…”

Management of early PEG tube dislodgement: simultaneous endoscopic closure of gastric wall defect and PEG replacement

“…The presence of pneumoperitoneum on CT or plain film imaging, regardless of its amount, after early PEG dislodgement is clinically meaningless because it is impossible to determine whether the intraluminal air escaped into the peritoneal cavity during the placement of the PEG tube or its dislodgment 30. On the other hand, the absence of peritoneal air is much more telling and clinically useful, signifying small-sized or closing gastric wall defect 30. The most important piece of information gleaned from CT imaging in this clinical setting is the distribution of the water-soluble oral contrast, with three distinct patterns identified 28 29.…”