3123 Massive Pneumoperitoneum Following G-Tube: Is Severe Constipation a Risk Factor?

Abstract

INTRODUCTION: Pneumoperitoneum has been shown to occur in approximately 5% of patients undergoing gastrostomy tube (G-tube) placement via esophagogastroduodenoscopy (EGD). Of those, only half have clinically significant symptoms normally in the setting of moderate to large pneumoperitoneum. We report a case of massive pneumoperitoneum presenting as an acute abdomen without overt perforation. CASE DESCRIPTION/METHODS: An 80-year-old male with recently diagnosed piriform sinus squamous cell carcinoma was directly referred to our endoscopy unit by his oncologist for G-tube placement given plans for chemoradiation. He was asymptomatic. We performed an EGD which revealed normal gastric and duodenal mucosa. A site was located in the gastric body and the stomach was insufflated revealing excellent transillumination and one-to-one manual external pressure. A 20Fr G-tube was successfully placed via the pull-guidewire technique. Post procedure, he was asymptomatic and tolerated an oral diet. Next day he presented to the emergency room with severe abdominal pain and distention. He was afebrile, tachycardic and had a rigidly distended abdomen. White blood cell count was 11.8 and lactic acid was 2.3. Computed tomography (CT) scan showed large free intraperitoneal air concerning for perforation. He was given antibiotics, kept NPO and seen by general surgery. Review of the CT scan showed the G-tube bumper in the stomach with oral contrast filling it without extravasation and dense stool burden filling the entire colon (Figure 1). Delayed images showed contrast in the small and large intestine without any extravasation. Polyethylene glycol solution was initiated via the G-tube resulting in numerous bowel movements and significant symptom improvement. Imaging performed 48 hours after revealed resolution of pneumoperitoneum and stool burden (Figure 2). He was discharged on a bowel regimen and continued to be asymptomatic at follow-up. DISCUSSION: This case illustrates the importance of clinical acumen when evaluating patients' post-procedure, as this patient's initial imaging and exam findings could have resulted in an unnecessary surgery. Further, we hypothesize insufflation during EGD in a patient with severe constipation can result in a high-pressure gradient driving air into the peritoneum via the iatrogenic perforation site. This case emphasizes caution in performing G-tube placement in patients with severe constipation and also highlights the potential pitfalls of a direct referral endoscopy system.