S3193 Symptomatic Pneumoperitoneum Following Gastrostomy Tube Placement Managed by Pneumocentesis

Abstract

Introduction: Percutaneous endoscopic gastrostomy (PEG) tube placement is a common procedure to provide enteral nutrition to patients who are not candidates for oral intake and those needing gastric decompression. Pneumoperitoneum, the presence of air in the peritoneal cavity, is a well-recognized complication of PEG tube placement. We present a case herein of a patient with persistent and clinically significant pneumoperitoneum managed by paracentesis with air evacuation, a previously unreported intervention in this clinical setting. Case Description/Methods: Our patient is a 72-year-old man with relevant medical history of tongue cancer treated with chemoradiation. He developed dysphagia and progressive weight loss despite nutritional supplements necessitating PEG tube placement. On post-op day one, he developed worsening abdominal pain and distention. A computed tomography (CT) of the abdomen was obtained and showed an appropriately placed PEG tube in the gastric body as well as moderate size pneumoperitoneum (Figure 1). Six days after the PEG tube placement, the patient’s symptoms had still not improved with conservative management. Interventional radiology was consulted, and patient underwent aspiration of air from the peritoneal cavity. Following air evacuation, abdominal pain promptly resolved and tube feeds were advanced to goal rate. The patient was seen two months later in the outpatient clinic and was gaining weight with PEG tube feeding and denied abdominal symptoms. Discussion: Pneumoperitoneum after PEG tube placement is typically considered a benign and self-limited finding. The etiology is likely related to elevated intragastric air pressures from the endoscope and escape of air from the stomach following needle puncture. If patients are asymptomatic without any signs of peritonitis, no further intervention is necessary other than monitoring. In our case, the patient’s symptoms failed to improve with conservative management. Thus, the decision was made to proceed with paracentesis with air evacuation by interventional radiology, resulting in the resolution of both the pneumoperitoneum and the patient’s symptoms. A literature review using Pubmed, Cochrane, and Medline uncovered no other cases of pneumoperitoneum following PEG tube placement that were managed with air evacuation.Figure 1.: 1a.- Histopathology showing lipid laden histiocytes 1b.- Endoscopic image of gastric nodule.