Persistent pneumoperitoneum after percutaneous endoscopic gastrostomy

Pneumoperitoneum after Percutaneous Endoscopic Gastrostomy in Patients in the Intensive Care Unit

Percutaneous endoscopic gastrostomy (PEG) has been associated with up to a 55 per cent incidence of pneumoperitoneum in the literature. A review was conducted of 120 consecutive PEG tube insertions in patients in the intensive care unit (ICU) to determine the incidence and significance of postprocedural pneumoperitoneum in this population. One hundred twenty consecutive PEG insertions in patients in the ICU were retrospectively reviewed. Chest radiographs were reviewed for 48 hours postprocedure, noting if any pneumoperitoneum was apparent on radiologic examination. If present, the time to resolution was noted. Documented PEG complications were also examined. Post-PEG pneumoperitoneum was detected in 6.7 per cent of patients in the ICU. Mean time to resolution was 2.7 days. The complication rate was 10.8 per cent, including dislodgement requiring laparotomy, transcolonic placement, and upper gastrointestinal bleeding. There were no complications resulting from PEG placement in patients with postprocedural pneumoperitoneum. Two transcolonic PEGs were undetected by postprocedure chest radiographs. The incidence of post-PEG pneumoperitoneum in our ICU population was 6.7 per cent. We believe that this incidence, although lower than historical rates, accurately reflects the current rate of detectable pneumoperitoneum in patients in the ICU. PEG-related complications were not associated with postprocedure pneumoperitoneum.

Spontaneous pneumoperitoneum and other nonsurgical causes of intraperitoneal free gas

Intraperitoneal free gas seen radiologically as air under the diaphragm nearly always indicates a perforated abdominal viscus that requires surgical intervention. Rarely, however, the presence of a pneumoperitoneum may not indicate an intra-abdominal perforation and thus may not require laparotomy. Such a situation is termed spontaneous or nonsurgical pneumoperitoneum. In this review, we explore the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. An appreciation of the condition and its likely aetiological factors should improve awareness and possibly reduce the imperative to perform an emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum.

Pneumoperitoneum following percutaneous endoscopic gastrostomy. Does the timing of panendoscopy matter?

Percutaneous endoscopic gastrostomy (PEG) has had a significant impact on enteral alimentation in patients unable to maintain adequate oral caloric intake. PEG avoids the morbidity and mortality associated with the traditional feeding gastrostomies placed by celiotomy. Several authors have documented benign, self-limiting pneumoperitoneum following PEG placement. No study has addressed whether the timing of panendoscopy in relation to gastric puncture has an effect on the incidence of post-PEG pneumoperitoneum. The authors prospectively studied 30 patients undergoing PEG. Panendoscopy was either performed before or after gastric puncture, and each patient then had abdominal radiographs to determine the presence of pneumoperitoneum. Four of 16 patients (25%) having panendoscopy prior to gastric puncture had radiographic evidence of pneumoperitoneum compared to three of 14 patients (23%) having panendoscopy following gastric puncture. The authors conclude that the timing of panendoscopy in relation to gastric puncture does not significantly effect the incidence of post-PEG pneumoperitoneum.