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

Reappraisal of Pneumoperitoneum After Percutaneous Endoscopic Gastrostomy

BACKGROUND/AIMS

Pneumoperitoneum is recognized as a benign and self-limiting finding after the insertion of a percutaneous endoscopic gastrostomy (PEG) tube, while complicated pneumoperitoneum is rarely reported. The aim of this study was to reappraise pneumoperitoneum following PEG.

METHODS

We retrospectively reviewed 193 patients who underwent PEG from May 2008 to May 2014. All patients had a follow-up upright chest or simple abdominal radiograph after PEG. Pneumoperitoneum was quantified by measuring the height of the air column under the diaphragm and graded as small (<2 cm), moderate (2-4 cm), or large (>4 cm). Clinically significant signs were defined as fever, abdominal tenderness or leukocytosis occurring after PEG insertion.

RESULTS

Of the 193 study patients, 9 (4.6%) had a pneumoperitoneum visualized by radiographic imaging, graded as small in 5 patients, moderate in 2 patients and large in 2 patients. Clinically significant signs were observed in 5 (55.5%) patients with fever reported in 4 patients, abdominal tenderness in 4 patients and leukocytosis in 4 patients. The time to resolution of free air was 2-18 days. Two patients (22.2%) with moderate or large pneumoperitoneum after PEG died from either pneumonia or septic shock.

CONCLUSIONS

The clinical course of pneumoperitoneum after PEG is not always benign and self-limiting. These findings suggest that clinicians should not neglect a moderate or large pneumoperitoneum, particularly in patients who have an altered mental status or received antibiotics, since peritoneal irritation cannot be observed under these circumstances.

Artificial nutrition: principles and practice of enteral feeding

Enteral feeding is a commonly used form of nutritional supplementation for patients with intestinal failure, both in hospitals and in the community. This article concentrates on the basic principles of enteral feeding, including the physiological effects of feeding into the intestinal tract. It covers the indications for enteral feeding, the different methods of supplying enteral feeds to the gastrointestinal tract, and the potential complications. There is also a discussion of the indications for and practice of home enteral nutrition.

[A case of spontaneous pneumoperitoneum associated with idiopathic intestinal pseudoobstruction]

Pneumoperitoneum, free intra-abdominal air, usually results from the perforation of a hollow viscous. In approximately 10% of cases, however, pneumoperitoneum is not caused by gastrointestinal perforation. These cases of "spontaneous pneumoperitoneum" generally follow more benign course and may not require surgical intervention. Examples include cardiopulmonary resuscitation (CPR), malrotation, mechanical ventilator support, gynecologic manipulation, blunt abdominal trauma, and chronic intestinal pseudoobstruction in infancy (Sieber syndrome). But, it is extremely rare of spontaneous pneumoperitoneum secondary to idiopathic intestinal pseudoobstruction in adult. We herein report a patient with chronic idiopathic intestinal pseudoobstruction who developed a pneumoperitoneum.

Prolonged postlaparoscopy carbon dioxide pneumoperitoneum

In this article we report what is to our knowledge the longest published duration of postlaparoscopy CO2 pneumoperitoneum, and discuss factors that may contribute to the duration of postoperative pneumoperitoneum.

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.

True incidence and clinical significance of pneumoperitoneum after PEG placement: a prospective study

BACKGROUND

PEG is a widely used method for providing nutritional support. Although pneumoperitoneum is a known finding after PEG placement, its true incidence is subject to debate. Small retrospective studies have found varied rates of free air after PEG placement.

PATIENTS

There were a total of 65 patients.

OBJECTIVE

To assess the true incidence of pneumoperitoneum and its clinical significance.

DESIGN

Prospective study.

SETTING

Long Island Jewish Medical Center.

INTERVENTIONS

We obtained upright and anterior-posterior chest radiographs of 65 patients within 3 hours after PEG placement. Type of PEG tube, gauge of the needle used, number of sticks, and indications were recorded. The presence of pneumoperitoneum on the initial chest film was considered to be a positive finding. After a positive result, a repeat chest film was obtained 72 hours later to determine whether there was progression or resolution of the free air. Patients enrolled in the study were also monitored clinically for evidence of peritonitis.

MAIN OUTCOME

Of the 65 patients who underwent PEG placement, 13 developed a pneumoperitoneum on the initial chest radiograph; there was complete resolution of pneumoperitoneum at 72 hours in 10 of the 13 patients. In 3 patients, the free air persisted but was of no clinical significance.

MEASUREMENTS

The free air was quantified by measuring the height of the air column under the diaphragm and was graded with a scoring system (0, no air; 1, small; 2, moderate; 3, large).

RESULTS

Eleven patients who underwent PEG died during the hospitalization; none of the deaths were related to the PEG placement or pneumoperitoneum. The other 54 patients were discharged to a skilled nursing facility. No patients in the study had clinical evidence of peritonitis. There were no adverse events, ie, infection or bleeding, associated with the PEG placement in any of the patients.

CONCLUSIONS

Our data suggest that pneumoperitoneum after PEG placement is common and, in the absence of clinical symptoms, is of no clinical significance and does not warrant any further intervention.

The Incidence and Significance of Free Air after Percutaneous Endoscopic Gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is well established as a safe and effective means of providing enteral feeding access in patients unable to tolerate oral feeding. There is some question, however, as to the true incidence of free air after PEG and the clinical significance of free air in these patients. We report our experience with 119 patients over 4 years who underwent placement of a percutaneous gastrostomy tube. This study is a retrospective review of percutaneous endoscopic gastrostomies performed by the Critical Care Service for Surgery (CCSS). A database of percutaneous endoscopic gastrostomies performed by the CCSS was maintained from September 1997 through December 2001. Complications of percutaneous gastrostomies were added to the database when noted. The electronic medical record of all patients was reviewed for the results of radiographic studies. Prior abdominal operations were noted as well as gastrostomy tube complications and outcome. A total of 115 intensive care unit patients underwent PEG placement by the CCSS. This total includes 18 patients who had undergone prior upper abdominal surgery, Three additional patients who underwent placement of a gastrostomy tube by vascular interventional radiology and one patient who underwent PEG placement by the ear, nose, and throat service were brought to the attention of CCSS secondary to complications for a total of 119 patients. Only four patients (3.4%) were found to have free air on subsequent chest radiograph. Six patients (5.2%) were found to have free air on abdominal CT scans. Two patients with free air on CT underwent exploratory celiotomy as a result of additional signs of peritonitis. Both were negative explorations. The incidence of free air after PEG in our experience is significantly less than the incidence in previous studies. In patients with free air after PEG placement exploratory celiotomy is not indicated in the absence of other clinical findings of peritonitis. Additionally it was noted that PEG placement could safely be performed in patients with prior upper abdominal surgery with a low incidence of complications.

Pneumoperitoneum: a review of nonsurgical causes

OBJECTIVE

To review causes of nonsurgical pneumoperitoneum (NSP), identify nonsurgical etiologies, and guide conservative management where appropriate.

DATA SOURCE

We conducted a computerized MEDLINE database search from 1970 to 1999 by using key words pneumoperitoneum and benign, nonsurgical, spontaneous, iatrogenic, barotrauma, pneumatosis, diaphragmatic defects, free air, mechanical ventilation, gynecologic, and pelvic. We identified 482 articles by using these keywords and reviewed all articles. Additional articles were identified and selectively reviewed by using key words laparotomy, laparoscopy, and complications.

STUDY SELECTION

We reviewed all case reports and reviews of NSP, defined as pneumoperitoneum that was successfully managed by observation and supportive care alone or that required a nondiagnostic laparotomy.

DATA SYNTHESIS

Each unique cause of nonsurgical pneumoperitoneum was recorded. When available, data on nondiagnostic exploratory laparotomies were noted. Case reports were organized by route of introduction of air into the abdominal cavity: abdominal, thoracic, gynecologic, and idiopathic.

CONCLUSIONS

Most cases of NSP occurred as a procedural complication or as a complication of medical intervention. The most common abdominal etiology of NSP was retained postoperative air (prevalence 25% to 60%). NSP occurred frequently after peritoneal dialysis catheter placement (prevalence 10% to 34%) and after gastrointestinal endoscopic procedures (prevalence 0.3% to 25%, varying by procedure). The most common thoracic causes included mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax. One hundred ninety-six case reports of NSP were recorded, of which 45 involved surgical exploration without evidence of perforated viscus. The clinician should maintain a high index of suspicion for nonsurgical causes of pneumoperitoneum and should recognize that conservative management may be indicated in many cases.

Peritonitis following percutaneous gastrostomy in children: management guidelines

BACKGROUND

To establish the incidence, timing and outcome of peritonitis following percutaneous gastrostomy (PEG) insertion in children.

METHODS

Patients developing peritonitis after PEG insertion during a 5-year period (1990-95) were identified. Variables analysed included clinical presentation, management, operative findings and outcome.

RESULTS

One hundred and twenty paediatric patients received 130 PEG in the 5-year period. Eight children developed peritonitis: 4 within 24 h of PEG insertion and 4 following routine PEG tube change (3-18 months later). All four patients developing early peritonitis underwent laparotomy in whom three had sustained major damage to adjacent viscera. The fourth patient had a negative laparotomy, but died from continued overwhelming sepsis. All four patients who developed peritonitis after a routine tube change underwent a tube contrast study. In two children a gastrocolic fistula was identified and surgically repaired. Contrast studies in two patients detected an intraperitoneal leak. This problem resolved with conservative management in both cases.

CONCLUSIONS

Peritonitis immediately following PEG insertion is rarely due to the air leakage during insertion (benign pneumoperitoneum) and warrants early laparotomy to identify and correct the likely associated visceral trauma. Following PEG tube change peritonitis may result from stomal separation or tube malposition and an urgent study is indicated to identify the cause.

Percutaneous endoscopic gastrostomy in paediatric practice: complications and outcome

PURPOSE

The aim of this study was to establish the morbidity and mortality of percutaneous endoscopic gastrostomy (PEG) in a tertiary referral paediatric practice and to identify risk factors for developing complications after a PEG.

METHODS

The medical records of all patients who had a percutaneous endoscopic gastrostomy attempted over a 5-year period (1990 to 1995) were reviewed.

RESULTS

One hundred thirty percutaneous gastrostomies were placed in 120 paediatric patients. Indications for insertion were inability to swallow (n = 74, of which, 52 were neurologically impaired), inadequate calorie intake (n = 30), special feeding requirements (n = 12), continuous enteral feeding in short gut (n = 2), and malabsorption (n = 2). All the children had complex medical problems, and 80% of the patients were rated as "high risk" for general anaesthesia (> or = ASA grade 3). Major complications developed in 21 children (17.5%) and minor complications in 27 (22.5%). Of the 17 children in whom gastroesophageal reflux (GOR) became symptomatic, 10 required a Nissen fundoplication. Nine of these 10 children were neurologically impaired (19% of the neurologically impaired children). One postrenal transplant patient on immunosuppression died 54 days after the procedure of intraabdominal sepsis. Thirty-one patients required secondary surgical procedures.

CONCLUSIONS

PEG is associated with significant morbidity. Neurologically impaired children are at risk of acquiring symptomatic GOR, but the risk does not warrant routine fundoplication. Major complications are common and need urgent surgical consultation with many requiring secondary surgical procedures. PEG in paediatric patients should be considered a major surgical undertaking.

Predictive factors for early mortality after percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a safe access procedure for enteral nutrition. The purpose of this investigation is to identify predictive factors for early mortality after PEG.

METHODS

A retrospective review of the hospital records of 416 patients undergoing PEG from June 1, 1989, through December 31, 1991, was conducted. Patient demographics, admitting diagnosis, indication for PEG, risk factors for early mortality, and cause and date of death were reviewed. Logistic regression analysis was used to develop a model to predict early mortality after PEG. The follow-up period ranged from 1 to 30 months.

RESULTS

The overall mortality rate in this review was 227 of 416 patients (54.6%). The 7- and 30-day case fatality rates were 39 of 416 (9.4%) and 97 of 416 (23.3%), respectively. Logistic regression analysis showed that urinary tract infection (odds ratio (OR) = 3.05; 95% confidence interval (CI) = 1.45-6.43) and previous aspiration (OR = 6.86; 95% CI = 3.27-14.4) were predictive factors for death at 1 week after PEG. Patients who had both risk factors had a 48.4% probability of dying within 7 days after PEG insertion, whereas those who had no risk factors had a 4.3% probability of death. Urinary tract infection (OR = 2.00; 95% CI = 1.17-3.41), previous aspiration (OR = 3.62; 95% CI = 2.00-6.55), and age greater than 75 years (OR = 2.49; 95% CI = 1.47-4.21) were predictive factors for death at 1 month after PEG. Patients who had all three risk factors had a 67.1% probability of death at 1 month while those who had no risk factors had a 10% probability of death.

CONCLUSIONS

A subgroup of patients exists that has a very high mortality rate after PEG. Less invasive ways of nutritionally supporting these high-risk patients should be evaluated.

Benign spontaneous pneumoperitoneum in an elderly patient treated medically with recovery

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Giant chest wall arteriovenous malformation with spinal cord compression

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