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Occult abdominal wall peristomal abscess following percutaneous endoscopic gastrostomy
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NUTRITION (1990) 9: 289-290 Group UK Ltd (1990)
0261-5614/90/ooo9-o289/810.00
Occult Abdominal Wall Peristomal Abscess Following Percutaneous Endoscopic Gastrostomy J.J.Payne-James, M. J. Bray, S. K. Rana, R. G. P. Rees and D. B. A.
Silk
Department of Gastroenterology and Nutrition, Central Middlesex Hospital, Acton Lane, London, UK (Reprint requests to J.J.P.-J.)
ABSTRACT This case report describes the complication of peristomal abscess formation associated with the insertion of a percutaneous endoscopic gastrostomy (PEG). The formation of a peristomal anterior abdominal wall abscess in this patient was associated with the failure to give prophylactic antibiotics. The development of this potentially fatal complication may be avoided by strict observance of insertion protocols. This case was treated by removal of the gastrostomy tube after diagnosis which allowed drainage of the abscess. In similar cases of occult abscess formation, where symptoms are present but signs are absent, ultrasonography may be useful in diagnosis.
CASE REPORT A 70-year-old Caucasian male presented with a 3month history of dysphagia associated with weight loss. Barium studies followed by endoscopy indicated the presence of a carcinoma of the cardia. Histology confirmed a poorly differentiated adenocarcinoma. Multiple metastases in right and left lobes of the liver were demonstrated by ultrasound and computed tomography. In view of the metastases palliation of dysphagia was undertaken using ethanol-induced tumour necrosis (ETN) [l]. The dysphagia improved allowing the patient to be discharged. ETN was repeated 6 weeks later as a day patient, when he also underwent dilation of the stricture with Celestin dilators. 6h later the patient developed severe epigastric pain with guarding. Gastrografin swallow confirmed a perforation localised to the lesser sac. He was treated conservatively with peripheral parenteral nutrition, and a repeat gastrografin swallow on day 10 showed no further leak. Dysphagia returned but endoscopy revealed a wide 1 cm channel through tumour. Because of symptoms of hunger and the patient’s eagerness to return home the decision was made to insert a percutaneous endoscopic gastrostomy to allow home enteral nutrition. The gastrostomy tube (Bower PEG, Corpak, Illinois, USA) was inserted uneventfully under benzodiaxepine sedation and local anaesthetic. The Unit protocol for PEG insertion was breached in that antibiotic cover (750 mg cefuroxime intravenously) was not administered until after the procedure instead of 30min before. 24 h after insertion (diet infusion having com-
menced the following morning) the patient complained of parastomal discomfort. Clinical examination was unremarkable and the patient was apyrexial. Ampicillin was prescribed for a chest infection two days after the procedure and discharge postponed. The patient continued to complain of increasing peristomal pain in the absence of any clinical signs. On day 7, a minor discharge of pus was noted around the gastrostomy. Clinical examination revealed peristomal fluctuance. PEG removal was undertaken using traction (endoscopic removal not being required for the Bower PEG). Following removal of the PEG, 50ml of pus discharged from the stoma. This was sterile on culture. Abdominal symptoms resolved completely within 24 h with a concurrent improvement in the patient’s wellbeing.
DISCUSSION Since the introduction of the technique of percutaneous endoscopic gastrostomy [2], two major complications, necrotising fasciitis of the anterior abdominal wall [3, 41 and persistent pneumoperitoneum, have been described [5]. In a recent series 6% of patients in whom PEG’s had been inserted developed ‘superficial wound infections’ [6]. These were treated with either antibiotics or incision and drainage of the wound, necessitating the removal of only one PEG. Some authors have drawn up protocols to reduce the incidence of infectious complications [3]. Prophylactic per-i-procedural antibiotics, and an adequate sized
290
OCCULT
ABDOMINAL
WALL PERISTOMAL
ABSCESS
incision (at least 1 cm) in the anterior abdominal wall to allow external drainage of blood or pus if required, are the two measures that may reduce the incidence of infective complications. A prospective study showed that cefazolin prophylaxis significantly reduced the incidence of wound infection [7]. Ponsky reported no wound infections in a large series of patients whose PEG’s were inserted with antibiotic cover, unlike an earlier series of PEG’s inserted without prophylaxis where wound infections were observed [8]. In view of the absence of clinical signs on the anterior abdominal wall in our patient, the abscess was probably sited posterior to the rectus abdominis muscle in the rectus sheath, or within the muscle itself. In addition, the use of antibiotics for a chest infection would have delayed development of clinical signs. A recent report has emphasised the potentially fatal outcome of abdominal wall abscesses, but in each case reported, definite signs and symptoms of abdominal wall infection were present [9]. Removal of the Bower PEG by traction externally in our patient (rather than by endoscopic removal) permitted adequate external drainage of the peristomal abscess. Had the PEG been of the type requiring endoscopic removal, satisfactory drainage of the abscess and resolution of symptoms may not have occurred. In that situation formal incision and drainage might have been required to avoid the risk of developing necrotising fasciitis or a septicaemia. The occult nature of this peristomal abscess emphasises that prolonged or persistent pain of any degree at the insertion site should not be considered normal or acceptable more than two or three days after PEG insertion. In the absence of clinical signs, but with continued symptoms further investigation
such as ultrasonography of the anterior abdominal wall should be considered in order that early diagnosis of potentially fatal abdominal wall abscesses is made.
REFERENCES [l] Payne-James J J, Spiller R C, Misiewicz J J, Silk D B A 1990 Use of ethanol-induced tumor necrosis to palliate dysphagia in patients with esophagogastric cancer. Gastrointestinal Endoscopy 36: 4346 121 . Gauderer M W L, Ponsky J L, Izant R J 1980 Gastrostomy without laparotomy: a percutaneous endoscopic technique. Journal of Pediatric Surgery 15: 872-875 [31 Greif J M, Ragland J J, Ochsner M G, Riding R 1986 Fatal necrotising fasciitis complicating percutaneous endoscopic gastrostomy. Gastrointestinal Endoscopy 32: 292-294 [41 Cave D R, Robinson W R, Brotschi E A 1986 Necrotising fasciitis following percutaneous endoscopic gastrostomy. Gastrointestinal Endoscopy 32: 294-296 PI Gottfried E B, Plurnser A B, Clair M R 1986 Pneumoperitoneum following percutaneous endoscopic gastrostomy. A prospective study. Gastrointestinal Endoscopy 32: 397-399 WI Larson D E, Burton D D, Schroeder K W, DiMagno E P 1987 Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 93: 48-52 17J Jain N K, Larson D E, Schroeder K W et al 1987 Antibiotic prophylaxis for percutaneous endoscopic gastrostomy. A prospective, randomised double-blind clinical trial. Annals of Internal Medicine 107: 824828 PI Ponskv J L, Gauderer M W L. Stellato T A 1983 Percu&eous endoscopic gastrostomy: review of 150 cases. Archives of Surgery 118: 913-914 191 Ditesheim J A, Richards W, Sharp K 1989 Fatal and disastrous complications following percutaneous endoscopic gastrostomy. American Surgeon 55: 92-96 1
Submission date: 22 January 1990. Accepted after revision: 26 April 1990
NUTRITION (1990) 9: 289-290 Group UK Ltd (1990)
0261-5614/90/ooo9-o289/810.00
Occult Abdominal Wall Peristomal Abscess Following Percutaneous Endoscopic Gastrostomy J.J.Payne-James, M. J. Bray, S. K. Rana, R. G. P. Rees and D. B. A.
Silk
Department of Gastroenterology and Nutrition, Central Middlesex Hospital, Acton Lane, London, UK (Reprint requests to J.J.P.-J.)
ABSTRACT This case report describes the complication of peristomal abscess formation associated with the insertion of a percutaneous endoscopic gastrostomy (PEG). The formation of a peristomal anterior abdominal wall abscess in this patient was associated with the failure to give prophylactic antibiotics. The development of this potentially fatal complication may be avoided by strict observance of insertion protocols. This case was treated by removal of the gastrostomy tube after diagnosis which allowed drainage of the abscess. In similar cases of occult abscess formation, where symptoms are present but signs are absent, ultrasonography may be useful in diagnosis.
CASE REPORT A 70-year-old Caucasian male presented with a 3month history of dysphagia associated with weight loss. Barium studies followed by endoscopy indicated the presence of a carcinoma of the cardia. Histology confirmed a poorly differentiated adenocarcinoma. Multiple metastases in right and left lobes of the liver were demonstrated by ultrasound and computed tomography. In view of the metastases palliation of dysphagia was undertaken using ethanol-induced tumour necrosis (ETN) [l]. The dysphagia improved allowing the patient to be discharged. ETN was repeated 6 weeks later as a day patient, when he also underwent dilation of the stricture with Celestin dilators. 6h later the patient developed severe epigastric pain with guarding. Gastrografin swallow confirmed a perforation localised to the lesser sac. He was treated conservatively with peripheral parenteral nutrition, and a repeat gastrografin swallow on day 10 showed no further leak. Dysphagia returned but endoscopy revealed a wide 1 cm channel through tumour. Because of symptoms of hunger and the patient’s eagerness to return home the decision was made to insert a percutaneous endoscopic gastrostomy to allow home enteral nutrition. The gastrostomy tube (Bower PEG, Corpak, Illinois, USA) was inserted uneventfully under benzodiaxepine sedation and local anaesthetic. The Unit protocol for PEG insertion was breached in that antibiotic cover (750 mg cefuroxime intravenously) was not administered until after the procedure instead of 30min before. 24 h after insertion (diet infusion having com-
menced the following morning) the patient complained of parastomal discomfort. Clinical examination was unremarkable and the patient was apyrexial. Ampicillin was prescribed for a chest infection two days after the procedure and discharge postponed. The patient continued to complain of increasing peristomal pain in the absence of any clinical signs. On day 7, a minor discharge of pus was noted around the gastrostomy. Clinical examination revealed peristomal fluctuance. PEG removal was undertaken using traction (endoscopic removal not being required for the Bower PEG). Following removal of the PEG, 50ml of pus discharged from the stoma. This was sterile on culture. Abdominal symptoms resolved completely within 24 h with a concurrent improvement in the patient’s wellbeing.
DISCUSSION Since the introduction of the technique of percutaneous endoscopic gastrostomy [2], two major complications, necrotising fasciitis of the anterior abdominal wall [3, 41 and persistent pneumoperitoneum, have been described [5]. In a recent series 6% of patients in whom PEG’s had been inserted developed ‘superficial wound infections’ [6]. These were treated with either antibiotics or incision and drainage of the wound, necessitating the removal of only one PEG. Some authors have drawn up protocols to reduce the incidence of infectious complications [3]. Prophylactic per-i-procedural antibiotics, and an adequate sized
290
OCCULT
ABDOMINAL
WALL PERISTOMAL
ABSCESS
incision (at least 1 cm) in the anterior abdominal wall to allow external drainage of blood or pus if required, are the two measures that may reduce the incidence of infective complications. A prospective study showed that cefazolin prophylaxis significantly reduced the incidence of wound infection [7]. Ponsky reported no wound infections in a large series of patients whose PEG’s were inserted with antibiotic cover, unlike an earlier series of PEG’s inserted without prophylaxis where wound infections were observed [8]. In view of the absence of clinical signs on the anterior abdominal wall in our patient, the abscess was probably sited posterior to the rectus abdominis muscle in the rectus sheath, or within the muscle itself. In addition, the use of antibiotics for a chest infection would have delayed development of clinical signs. A recent report has emphasised the potentially fatal outcome of abdominal wall abscesses, but in each case reported, definite signs and symptoms of abdominal wall infection were present [9]. Removal of the Bower PEG by traction externally in our patient (rather than by endoscopic removal) permitted adequate external drainage of the peristomal abscess. Had the PEG been of the type requiring endoscopic removal, satisfactory drainage of the abscess and resolution of symptoms may not have occurred. In that situation formal incision and drainage might have been required to avoid the risk of developing necrotising fasciitis or a septicaemia. The occult nature of this peristomal abscess emphasises that prolonged or persistent pain of any degree at the insertion site should not be considered normal or acceptable more than two or three days after PEG insertion. In the absence of clinical signs, but with continued symptoms further investigation
such as ultrasonography of the anterior abdominal wall should be considered in order that early diagnosis of potentially fatal abdominal wall abscesses is made.
REFERENCES [l] Payne-James J J, Spiller R C, Misiewicz J J, Silk D B A 1990 Use of ethanol-induced tumor necrosis to palliate dysphagia in patients with esophagogastric cancer. Gastrointestinal Endoscopy 36: 4346 121 . Gauderer M W L, Ponsky J L, Izant R J 1980 Gastrostomy without laparotomy: a percutaneous endoscopic technique. Journal of Pediatric Surgery 15: 872-875 [31 Greif J M, Ragland J J, Ochsner M G, Riding R 1986 Fatal necrotising fasciitis complicating percutaneous endoscopic gastrostomy. Gastrointestinal Endoscopy 32: 292-294 [41 Cave D R, Robinson W R, Brotschi E A 1986 Necrotising fasciitis following percutaneous endoscopic gastrostomy. Gastrointestinal Endoscopy 32: 294-296 PI Gottfried E B, Plurnser A B, Clair M R 1986 Pneumoperitoneum following percutaneous endoscopic gastrostomy. A prospective study. Gastrointestinal Endoscopy 32: 397-399 WI Larson D E, Burton D D, Schroeder K W, DiMagno E P 1987 Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology 93: 48-52 17J Jain N K, Larson D E, Schroeder K W et al 1987 Antibiotic prophylaxis for percutaneous endoscopic gastrostomy. A prospective, randomised double-blind clinical trial. Annals of Internal Medicine 107: 824828 PI Ponskv J L, Gauderer M W L. Stellato T A 1983 Percu&eous endoscopic gastrostomy: review of 150 cases. Archives of Surgery 118: 913-914 191 Ditesheim J A, Richards W, Sharp K 1989 Fatal and disastrous complications following percutaneous endoscopic gastrostomy. American Surgeon 55: 92-96 1
Submission date: 22 January 1990. Accepted after revision: 26 April 1990