A 73-year-old man had swallowing difficulties because of a recent
cerebrovascular accident, and was on enteral feeding via a nasogastric tube.
Percutaneous endoscopic gastrostomy (PEG) was chosen for long-term enteral
feeding. Before the PEG tube was inserted, a flexible endoscope was inserted
into the stomach for inspection. No gross abnormal lesion was detected in the
upper gastrointestinal tract ([Fig. 1]).
Fig. 1 No gross abnormalities
were found when a flexible endoscope was inserted into the stomach.
Then, before puncturing, the stomach was insufflated and indentation
of the gastric lumen was confirmed by finger palpation of the abdominal wall.
This caused the patient to choke a few times. Subsequently, bleeding occurred
in the upper stomach. Several fusiform-shaped tears had developed along the
lesser curvature of the proximal stomach ([Fig. 2]).
Fig. 2 During gastric
insufflations, performed before puncture of the stomach for a percutaneous
endoscopic gastrostomy (PEG), several fusiform-shaped tears developed along the
lesser curvature of the proximal stomach.
Computed tomography (CT) imaging revealed pneumoperitoneum ([Fig. 3 a]) and pneumomediastinum ([Fig. 3 b]), requiring emergency
laparotomy.
Fig. 3 Computed tomography (CT)
imaging revealed a massive pneumoperitoneum and
b pneumomediastinum.
A 2-cm-long full-thickness tear along the lesser curvature of the
stomach close to the cardia was identified and sutured.
Gastric rupture is caused by increased gastric pressure resulting
from increased intra-abdominal pressure, with or without overdistention caused
by food or gas. In more than 70 % of the adult cases, gastric
rupture occurs in the less distensible proximal lesser curvature of the stomach
[1]. Spontaneous gastric rupture occurs due to vomiting,
vigorous coughing, or convulsion. Its cause may also be iatrogenic, resulting
from cardiopulmonary resuscitation, inadvertent esophageal intubation, Heimlich
maneuver, or esophagogastroduodenoscopy (EGD) [1]
[2]
[3].
Diagnostic EGD is extremely safe, and perforation of the
gastrointestinal tract is rare with an incidence of
0.001 % – 0.05 %
[4]. Gastric rupture during gastric insufflations, which
are performed before puncturing the stomach for a PEG, is also rarely reported
[5]. Endoscopic gastric insufflation with air is
important to avoid colon injury. In the present case, the patient’s
choking during gastric insufflations, which led to a sudden increase in
intra-abdominal pressure, may have caused the gastric rupture. Endoscopists
should consider this rare yet potentially lethal complication.
Endoscopy_UCTN_Code_CPL_1AH_2AI
