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Persistent abdominal distention after endoscopic PEG tube replacement
Journal Pre-proof Persistent abdominal distention after endoscopic PEG tube replacement Jae Keun Kim, Jin Woong Park, Kee Myung Lee
PII: DOI: Reference:
S0016-5085(19)41187-6 https://doi.org/10.1053/j.gastro.2019.07.056 YGAST 62812
To appear in: Gastroenterology Accepted Date: 29 July 2019 Please cite this article as: Kim JK, Park JW, Lee KM, Persistent abdominal distention after endoscopic PEG tube replacement, Gastroenterology (2019), doi: https://doi.org/10.1053/j.gastro.2019.07.056. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by the AGA Institute
Persistent abdominal distention after endoscopic PEG tube replacement
Jae Keun Kim1, Jin Woong Park2, Kee Myung Lee2 1
Department of Radiology, Ajou University Medical School, Suwon, Korea
2
Department of Gastroenterology, Ajou University Medical School, Suwon, Korea
Jae Keun Kim: drafting of the manuscript Jin Woong Park: acquisition of data Kee Myung Lee: study concept and design
Corresponding author: Kee Myung Lee 16502 Worldcup-ro 206 Woncheon-dong Yeongtong-gu Suwon Korea E-mail: [email protected] Cellular phone: 82-10-4537-1212 Phone: 882-31-219-6939
The authors declares that there is no conflict of interests regarding the publication of this article. Kim Jae Keun Jin Woong Park Kee Myung Lee
Question A 38-year-old man presented with abdominal distention and irritability. He was in a semi-coma after traumatic intracerebral hemorrhage 12 years ago. He had percutaneous endoscopic gastrostomy (PEG) 8 years ago and has changed tube 7 times. The patient visited to emergency department with persistent abdominal distention and irritability after endoscopic assistant tube change several hours before. Abdominal distention used to be subsided immediately after PEG tube had been replaced in the past. However, the abdominal distention was not improved at this time and the patient gradually became unstable and irritable. Blood pressure was 150/80 mmHg and tachypnea (18/min) and tachycardia (110/min) were noted. The physical examination showed diffuse tenderness on upper distended abdomen and breathing sound was decreased. Laboratory studies showed white blood cell count of 19,500/mL (normal, <11,000/ mL), C-reactive protein of 5.23 mg/dL (normal, <0.5 mg/ dL), lactic acid 2.89 mmol/L (normal, 0.70-2.00 mmol/L), hemoglobin 15.5 g/dL (normal, 12.5-17.5 g/dL) other laboratory data were within normal limits. A contrast-enhanced abdominal computed tomography (CT) scan was done. What is the diagnosis?
Answer. Massive gastric emphysema after PEG tube replacement CT scan demonstrated huge gastric wall emphysema (red arrow) and the gastric lumen was collapsed by intramural gas (yellow arrow) (Figure A). The patient maintained fasting and intravenous antibiotics, hydration, and nasal oxygen were supplied. Two day later, the abdominal distention subsided and the patient condition was improved. Follow up CT scan showed markedly decreased gastric emphysema (Figure B). Endoscopy demonstrated chronic superficial gastritis and PEG bumper was well positioned. Gastric emphysema is a rare condition defined as gastric intramural air without an underlying infection.1 Gastric emphysema is caused by a disruption in gastric mucosal integrity causing the entry of air into the wall. Increased intragastric pressure, endoscopic or instrumental trauma, severe vomiting, gastric outlet obstruction can cause gastric emphysema with excellent prognosis.1 Gastric ischemia is another etiology for gastric emphysema and hepatic portal venous gas, which may present with an acute abdomen.1 Early complications related to the PEG procedure usually occur during the first tube insertion, however replacement of gastrostomy tube is generally considered as a safe and simple procedure.2 Gastric emphysema is very rare complication of tube replacement.3 Gastrocutaneous tract of PEG is more friable than that of surgical gastrostomy because there is no suture fixation.3 So, clinician should always consider the possibility of other complication if the abdominal distention is persistent and the patient s condition is unstable after tube replacement.
Reference 1.
Matsushima K, Won EJ, Tangel MR, et al. Emphysematous gastritis and gastric emphysema: similar radiographic findings, distinct clinical entities. World J Surg. 2015; 39:1008-17.
2.
Hucl T, Spicak J. Complications of percutaneous endoscopic gastrostomy. Best Pract Res Clin Gastroenterol. 2016; 30:769-781.
3.
V Lohsiriwat. Percutaneous endoscopic gastrostomy tube replacement: A simple procedure?
World J Gastrointest Endosc. 2013; 16:14 18.
PII: DOI: Reference:
S0016-5085(19)41187-6 https://doi.org/10.1053/j.gastro.2019.07.056 YGAST 62812
To appear in: Gastroenterology Accepted Date: 29 July 2019 Please cite this article as: Kim JK, Park JW, Lee KM, Persistent abdominal distention after endoscopic PEG tube replacement, Gastroenterology (2019), doi: https://doi.org/10.1053/j.gastro.2019.07.056. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by the AGA Institute
Persistent abdominal distention after endoscopic PEG tube replacement
Jae Keun Kim1, Jin Woong Park2, Kee Myung Lee2 1
Department of Radiology, Ajou University Medical School, Suwon, Korea
2
Department of Gastroenterology, Ajou University Medical School, Suwon, Korea
Jae Keun Kim: drafting of the manuscript Jin Woong Park: acquisition of data Kee Myung Lee: study concept and design
Corresponding author: Kee Myung Lee 16502 Worldcup-ro 206 Woncheon-dong Yeongtong-gu Suwon Korea E-mail: [email protected] Cellular phone: 82-10-4537-1212 Phone: 882-31-219-6939
The authors declares that there is no conflict of interests regarding the publication of this article. Kim Jae Keun Jin Woong Park Kee Myung Lee
Question A 38-year-old man presented with abdominal distention and irritability. He was in a semi-coma after traumatic intracerebral hemorrhage 12 years ago. He had percutaneous endoscopic gastrostomy (PEG) 8 years ago and has changed tube 7 times. The patient visited to emergency department with persistent abdominal distention and irritability after endoscopic assistant tube change several hours before. Abdominal distention used to be subsided immediately after PEG tube had been replaced in the past. However, the abdominal distention was not improved at this time and the patient gradually became unstable and irritable. Blood pressure was 150/80 mmHg and tachypnea (18/min) and tachycardia (110/min) were noted. The physical examination showed diffuse tenderness on upper distended abdomen and breathing sound was decreased. Laboratory studies showed white blood cell count of 19,500/mL (normal, <11,000/ mL), C-reactive protein of 5.23 mg/dL (normal, <0.5 mg/ dL), lactic acid 2.89 mmol/L (normal, 0.70-2.00 mmol/L), hemoglobin 15.5 g/dL (normal, 12.5-17.5 g/dL) other laboratory data were within normal limits. A contrast-enhanced abdominal computed tomography (CT) scan was done. What is the diagnosis?
Answer. Massive gastric emphysema after PEG tube replacement CT scan demonstrated huge gastric wall emphysema (red arrow) and the gastric lumen was collapsed by intramural gas (yellow arrow) (Figure A). The patient maintained fasting and intravenous antibiotics, hydration, and nasal oxygen were supplied. Two day later, the abdominal distention subsided and the patient condition was improved. Follow up CT scan showed markedly decreased gastric emphysema (Figure B). Endoscopy demonstrated chronic superficial gastritis and PEG bumper was well positioned. Gastric emphysema is a rare condition defined as gastric intramural air without an underlying infection.1 Gastric emphysema is caused by a disruption in gastric mucosal integrity causing the entry of air into the wall. Increased intragastric pressure, endoscopic or instrumental trauma, severe vomiting, gastric outlet obstruction can cause gastric emphysema with excellent prognosis.1 Gastric ischemia is another etiology for gastric emphysema and hepatic portal venous gas, which may present with an acute abdomen.1 Early complications related to the PEG procedure usually occur during the first tube insertion, however replacement of gastrostomy tube is generally considered as a safe and simple procedure.2 Gastric emphysema is very rare complication of tube replacement.3 Gastrocutaneous tract of PEG is more friable than that of surgical gastrostomy because there is no suture fixation.3 So, clinician should always consider the possibility of other complication if the abdominal distention is persistent and the patient s condition is unstable after tube replacement.
Reference 1.
Matsushima K, Won EJ, Tangel MR, et al. Emphysematous gastritis and gastric emphysema: similar radiographic findings, distinct clinical entities. World J Surg. 2015; 39:1008-17.
2.
Hucl T, Spicak J. Complications of percutaneous endoscopic gastrostomy. Best Pract Res Clin Gastroenterol. 2016; 30:769-781.
3.
V Lohsiriwat. Percutaneous endoscopic gastrostomy tube replacement: A simple procedure?
World J Gastrointest Endosc. 2013; 16:14 18.