Successful nutritional support for a dysphagic patient with massive cirrhotic ascites and intrathoracic stomach using percutaneous endoscopic gastrostomy (PEG)

Abstract

Although massive cirrhotic ascites is generally considered a contraindication for the placement of percutaneous endoscopic gastrostomy (PEG), such patients are usually poorly nourished. Preceding paracentesis of ascites is one method for controlling ascites and allowing the safe placement of PEG, but it often results in overuse of albumin. Preceding peritoneal-venous (P-V) shunting can avoid excessive use of albumin, but this introduces the risk of infectious contamination. We encountered an 88-y-old woman with massive cirrhotic ascites, a giant esophageal hernia with dislocation of the proximal stomach into the mediastinum, hypertrophy of the lateral segment of the liver, and malnutrition who had suffered from appetite loss and a swallowing disorder for 4 mo. She underwent PEG using a staged sequential introduction method using a Funada-style gastric wall fixation kit as follows: 1) full stretching and pushing out of the stomach from the mediastinum into the peritoneal cavity by deep insertion and a turning-over procedure of the endoscope, 2) full distention by air to adhere the gastric wall to the peritoneal wall without migration of the colon, 3) four-point square fixation under gastroenterological endoscopy without migration of the visceral organ, and 4) puncture of the needle introducer of the PEG tube in the center of the fixations under repeated gastroenterological endoscopy 3 d after the fixation. She underwent P-V shunting under local anesthesia on the 28th day after placement of PEG and enteral nutrition. Her case shows that we can achieve proper enteral nutritional support even for patients with massive cirrhotic ascites.