Large pneumoperitoneum following PEG placement attempt

Case contributed by Dr Amy Attaway MD

Presentation

65-year-old male with a diagnosis of ALS who underwent elective PEG placement due to weight loss and dysphagia.

Patient Data

Age: 65
Gender: Male

Chest and upper abdominal x-ray was significant for the large volume of pneumoperitoneum. 

Repeat six hours later

Modality: X-ray

A repeat x-ray performed less than 6 hours later showed complete resolution of subdiaphragmatic air.

This is likely due to the usage of CO2 for insufflation during the procedure.

Case Discussion

During the procedure the wire had difficulty advancing externally from the stomach and was noted to be tense. General surgery was consulted and the area of the incision was extended. The wire was then extracted, and during the extraction there was an audible “pop.” Post procedure the patient had abdominal distention and increased work of breathing as well as dyspnea and hypoxia. He required 100% non-rebreather and was saturating low 90% for approximately one hour. His chest and upper abdominal x-ray was significant for pneumoperitoneum. However, his abdominal distention and respiratory status would improve over the next several hours and a repeat x-ray performed less than 6 hours later showed complete resolution of subdiaphragmatic air. The patient had PEG placement performed 2 days later without complication.

Pneumoperitoneum following percutaneous endoscopic gastrostomy tube placement is a common complication. Its incidence is noted to be approximately 20% in one series. Amongst these cases, only 4.6% had subdiaphragmatic air visualized after 72 hours and none of these cases were found to be clinically significant 1. CO2 has been increasingly used for insufflation due to its rapid absorption and has been shown to reduce the frequency of post-PEG pneumoperitoneum 2.

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Case Information

rID: 42726
Case created: 5th Feb 2016
Last edited: 5th Feb 2016
Inclusion in quiz mode: Included

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