- Email: [email protected]
Subcutaneous emphysema following PEG
back, keeping the marked area outside the patient's abdomen. REFERENCES 1. Ho CS, Yee AC, McPherson R. Complications of surgical and
percutaneous nonendoscopic gastrostomy: review of 233 patients. Gastroenterology 1988;95:1206-10. 2. Larson DE, Burton DD, Schroeder KW, DiMagio EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroen-
terology 1987;93:48-52. 3. Wasiljew BK, Ujik GT, Beal JM. Feeding gastrostomy: complications and mortality. Am J Surg 1982;143:194-5. 4. Shellito PC, Malt RA. Tube gastrostomy. Ann Surg 1985;201: 180-4. 5. Haws EB, Sieber WK, Kieseweller WE. Complications of tube gastrostomy in infants and children. Ann Surg 1966;164:28490. 6. Fischer LS, Bonello JC, Greenburg E. Gastrostomy tube migration and gastric outlet obstruction following percutaneous endoscopic gastrostomy. Gastrointest Endosc 1987;33:381-2.
Subcutaneous emphysema following PEG George Stathopoulos, MD Mark A. Rudberg, MD James M. Harig, MD
Subcutaneous emphysema is an uncommon occurrence following placement of a PEG tube. This report details two cases and reviews the literature regarding the presentation, management, etiology, and possible prevention of this entity. CASE 1
A 74-year-old hypertensive alcoholic woman was admitted to the hospital after being found unresponsive with intermittent seizures at home. Imaging studies demonstrated a left frontal contusion and subdural hematoma. Mental status following treatment improved to one of intermittent wakefulness without ability for self-care. Given the need for long-term tube feeding, the gastroenterology service was consulted for placement of a PEG tube. No contraindications to PEG placement were present. Esophagogastroduodenoscopy at the time of tube placement revealed a distal esophageal web with a normal stomach and gastric outlet. The PEG tube was placed using the "introducer" or Russell method. 1 An appropriate puncture site was confirmed by maximal light transillumination and finger indentation. A single needle stab was made through the anterior wall of the gastric body. Sequential dilators were passed over a tethered guidewire, with subsequent placement of an 18 F Foley catheter, facilitated by a I-em skin incision. Periprocedural antibiotics (cefazolin) were administered. No immediate complications were evident. Six hours following the procedure the patient developed a low-grade temperature. Physical examination revealed crepitus extending from the gastrostomy site to the anterior abdominal and chest walls and both flanks. Plain films confirmed the presence of subcutaneous gas in the abdominal and thoracic areas (Fig. 1). The gastrostomy site was From the Department of Medicine, Sections of Gastroenterology and General Internal Medicine, University of Chicago Medical Center and Oak Forest Hospital, Chicago and Oak Forest, Illinois. Reprint requests: James W. Harig, MD, Section of Gastroenterology, Box 400, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, Illinois 60637.
374
Figure 1. Chest radiograph from patient 1. Arrow shows air in the subcutaneous tissues of the left chest.
without erythema, induration, or purulent drainage, and the abdominal examination was otherwise normal. The PEG tube was not utilized, the patient was kept fasting and parenteral nutrition and antibiotics were continued for 14 days. The patient's temperature slowly normalized. Subsequent physical examinations demonstrated resolution of the crepitus (over a 2-week period) and tube feedings were instituted without incident. The patient was subsequently discharged to a nursing care facility. CASE 2
An 88-year-old woman with a history of severe dementia was admitted to the hospital with infection and malnutrition. Given the inability to obtain adequate caloric intake by the oral route, a PEG tube was recommended as the best alternative for long-term enteral feeding. No contraindications to PEG placement were present and esophagogastroduodenoscopy at the time of tube placement was normal. The PEG tube was placed by the double endoscopic "pull" method as described by Gauderer et al. 2 At the point of maximal light transillumination and finger indentation, a needle stab was made into the stomach, with uneventful placement of the PEG tube, through a I-em skin incision. Immediate repeat endoscopy confirmed proper positioning of the tube which was secured into place. Peri-procedural GASTROINTESTINAL ENDOSCOPY
Figure 2. Radiograph of the upper chest and neck from patient 2. The arrows illustrate air in the subcutaneous tissues of the upper chest and neck.
antibiotics (cefoxitin) were administered and no immediate complications were evident. Tube feedings were initiated the following day without incident and were tolerated well. Seven days after tube placement, crepitus was noted along the anterior chest wall extending to the neck. Subcutaneous air was confirmed by plain films of the upper chest and neck (Fig. 2). The patient was afebrile and otherwise stable. The gastrostomy site was without erythema, induration, or drainage. Feedings were continued under close observation and proceeded without incident. The crepitus resolved 5 days following its onset.
DISCUSSION
Subcutaneous emphysema (SE) may arise from the forceful introduction of air through cutaneous and subcutaneous tissues, from soft tissue infection by gasproducing organisms, or via spontaneous disease-related, or iatrogenically induced rupture of an air filled cavity or viscus. 3 Subcutaneous emphysema of gastrointestinal origin is uncommon, but may result from spontaneous esophageal rupture (Boerhaave's syndrome), gastric or intestinal perforation secondary to ulcer disease, intestinal perforation secondary to diverticulitis, neoplastic disease, inflammatory bowel disease, infectious causes, and foreign body perforation. 4 Subcutaneous emphysema has been reported following a variety of endoscopic procedures, including esophagogastroduodenoscopy with perforation of a piriform sinus,5 colonscopy,6 colonoscopic polypectomy 7 and endoscopic sphincterotomy. 8 Subcutaneous emphysema following PEG placement is apparently uncommon. Our two cases bring to five the number of patients reported in the literature. Orchard and Barlow9 reported SE six days following PEG placement. A benign course (3 weeks to resolution) ruled out infection with gas-producing organisms as a cause. Bronner lO reported crepitus and VOLUME 37, NO.3, 1991
SE in a patient following inadvertent endotracheal tube placement into the esophagus 24 hours after uneventful PEG tube placement. Steffes et al.l! reported one patient who developed SE 5 days postprocedure without signs of infection. SE has also been reported following percutaneous gastrostomy by radiologic means12.13 and following surgical jejunostomy.14 Pneumatosis intestinalis has been noted with 14 and without SE 15 following surgical jejunostomy. Benign subcutaneous emphysema (BSE) must be distinguished from necrotizing fasciitis which has been observed following PEG placement.16-20 BSE presents hours to days following tube placement (range, 7 hours to 7 days in the five cases reported). An early presentation of crepitus (less than 48 to 72 hours postprocedure) seems to be more characteristic of BSE than necrotizing fasciitis. Although the initial presentation of necrotizing fasciitis may be insidious, the first manifestation is one of high fever (2 to 3 days post-tube placement) followed by erythema, induration, purulent drainage, and crepitus at the tube exit site, culminating in sepsis and clinical deterioration. High fever associated with signs of an infected gastrostomy site are not manifestations of BSE. BSE observed soon after percutaneous gastrostomy probably results from the dissection of intragastric air during the procedure through the subcutaneous tissues at the tube exit site. Insufflation of air via the endoscope may be an important contributing factor. Intraluminal pressures greater than 70 mm Hg (95 em H 20) may be seen with endoscopic air insufflation,21 whereas soft tissue pressures are only 5 em of H 20. 22 BSE that develops remotely following a PEG procedure is likely due to a large pressure gradient between the gastric lumen and subcutaneous tissues that is maintained by normal gastric contractile activity.22 This is especially true during vigorous abdominal wall contractions as seen with coughing and retching (P. J. Kahrilas, personal communication). Conceivably, snug placement of a PEG tube will not allow air to escape to the atmosphere via the gastrostomy site, thereby forcing a dissection of air into the subcutaneous space. Prevention of this entity requires an alternative route for drainage of intra-gastric air. A generous skin incision made at the time of tube placement has been advocated as a preventative measure for the development of both BSE and local infection.9.16.23 A patulous skin incision allows for drainage of intra-gastric air and fluid out the tube exit site versus dissection through subcutaneous tissues. This is necessary until sufficient scarring of the tract occurs, thereby preventing leakage of air underneath the skin. Absence of intraperitoneal or subcutaneous infection suggests the diagnosis of BSE. Once diagnosed, 375
the only treatment required is that of observation. Tube feedings can be continued once the diagnosis is certain. Antibiotics are not routinely necessary unless signs of infection become evident. Necrotizing fasciitis, however, requires aggressive surgical and medical therapy. Continued observation of the patient with BSE for signs of infection is mandatory. Crepitus should resolve within 1 to 3 weeks after initial onset.
REFERENCES 1. Russell TR, Brotman M, Norris F. Percutaneous gastrostomy. A new simplified and cost-effective technique. Am J Surg 1984;148:132-7. 2. Gauderer MWL, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5. 3. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema; pathophysiology, diagnosis and management. Arch Interm Med 1984;144:1447-53. 4. Walker MJ, Mozes MF. Massive subcutaneous emphysema: an unusual presentation of jejunal perforation. Am Surg 1981;47:45-8. 5. Burstein FD, Colman MF. A dramatic complication of peroral fiberoptic endoscopy. Head Neck Surg 1985;8:28-30. 6. Lezak MB, Goldhamer M. Retroperitoneal emphysema after colonoscopy. Gastroenterology 1974;66:118-20. 7. Humphreys F, Hewetson KA, Dellipiani AW. Massive subcutaneous emphysema following colonoscopy. Endoscopy 1984;16:160-1. 8. Tam F, Prindiville T, Wolfe B. Subcutaneous emphysema as a complication of endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1989;35:447-9. 9. Orchard JL, Barlow J. Benign subcutaneous emphysema after percutaneous endoscopic gastrostomy. Gastrointest Endosc 1987;33:51.
376
10. Bronner MH. Percutaneous endoscopic gastrostomy and crepitus. Gastrointest Endosc 1987;33:270-1. 11. Steffes C, Weaver DW, Bouwman DL. Percutaneous endoscopic gastrostomy. New technique-old complications. Am Surg 1989;55:273-277. 12. Wojtowycz MM, Arata JA. Subcutaneous emphysema after percutaneous gastrostomy. Am J RadioI1988;151:311-2. 13. Wills JS, Oglesby JT. Percutaneous gastrostomy. Radiology 1983;149:449-53. 14. Cogbill TH, Wolfson RH, Moore EE, et al. Massive pneumatosis intestinalis and subcutaneous emphysema: complication of needle catheter jejunostomy. J Parenter Enter Nutr 1983;7:171-5. 15. Zern RT, Clarke-Pearson DL. Pneumatosis intestinalis associated with enteral feeding by catheter jejunostomy. Obstet Gynecol 1985;65(suppl):81S-3S. 16. Grief JM, Ragland JJ, Ochsner MG, Riding R. Fatal necrotizing fasciitis complicating percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:292-4. 17. Cave DR, Robinson WR, Brotschi EA. Necrotizing fasciitis following percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:294-6. 18. Person JL, Brower RA. Necrotizing fasciitis/myositis following percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:309. 19. Komia J, Rice HE. Necrotizing fasciitis and percutaneous gastrostomy. Gastrointest Endosc 1987;33:335-6. 20. Haas DW, Dharmaraja P, Morrison JG, Potts JR. Necrotizing fasciitis following percutaneous endoscopic gastrostomy. Gastrointest Endosc 1988;34:487-8. 21. Kozarek RA, Sanowski RA. Use of pressure relief valve to prevent colonic injury during colonoscopy. Gastrointest Endosc 1980;26:139-42. 22. Quigley JP, Brody DA. A physiologic and clinical study of the pressure developed in the digestive tract. Am J Med 1952;13:7381. 23. Ponsky JL. PEG: no minor surgery [Editorial]. Gastrointest Endosc 1986;32:300-1.
GASTROINTESTINAL ENDOSCOPY
percutaneous nonendoscopic gastrostomy: review of 233 patients. Gastroenterology 1988;95:1206-10. 2. Larson DE, Burton DD, Schroeder KW, DiMagio EP. Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroen-
terology 1987;93:48-52. 3. Wasiljew BK, Ujik GT, Beal JM. Feeding gastrostomy: complications and mortality. Am J Surg 1982;143:194-5. 4. Shellito PC, Malt RA. Tube gastrostomy. Ann Surg 1985;201: 180-4. 5. Haws EB, Sieber WK, Kieseweller WE. Complications of tube gastrostomy in infants and children. Ann Surg 1966;164:28490. 6. Fischer LS, Bonello JC, Greenburg E. Gastrostomy tube migration and gastric outlet obstruction following percutaneous endoscopic gastrostomy. Gastrointest Endosc 1987;33:381-2.
Subcutaneous emphysema following PEG George Stathopoulos, MD Mark A. Rudberg, MD James M. Harig, MD
Subcutaneous emphysema is an uncommon occurrence following placement of a PEG tube. This report details two cases and reviews the literature regarding the presentation, management, etiology, and possible prevention of this entity. CASE 1
A 74-year-old hypertensive alcoholic woman was admitted to the hospital after being found unresponsive with intermittent seizures at home. Imaging studies demonstrated a left frontal contusion and subdural hematoma. Mental status following treatment improved to one of intermittent wakefulness without ability for self-care. Given the need for long-term tube feeding, the gastroenterology service was consulted for placement of a PEG tube. No contraindications to PEG placement were present. Esophagogastroduodenoscopy at the time of tube placement revealed a distal esophageal web with a normal stomach and gastric outlet. The PEG tube was placed using the "introducer" or Russell method. 1 An appropriate puncture site was confirmed by maximal light transillumination and finger indentation. A single needle stab was made through the anterior wall of the gastric body. Sequential dilators were passed over a tethered guidewire, with subsequent placement of an 18 F Foley catheter, facilitated by a I-em skin incision. Periprocedural antibiotics (cefazolin) were administered. No immediate complications were evident. Six hours following the procedure the patient developed a low-grade temperature. Physical examination revealed crepitus extending from the gastrostomy site to the anterior abdominal and chest walls and both flanks. Plain films confirmed the presence of subcutaneous gas in the abdominal and thoracic areas (Fig. 1). The gastrostomy site was From the Department of Medicine, Sections of Gastroenterology and General Internal Medicine, University of Chicago Medical Center and Oak Forest Hospital, Chicago and Oak Forest, Illinois. Reprint requests: James W. Harig, MD, Section of Gastroenterology, Box 400, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, Illinois 60637.
374
Figure 1. Chest radiograph from patient 1. Arrow shows air in the subcutaneous tissues of the left chest.
without erythema, induration, or purulent drainage, and the abdominal examination was otherwise normal. The PEG tube was not utilized, the patient was kept fasting and parenteral nutrition and antibiotics were continued for 14 days. The patient's temperature slowly normalized. Subsequent physical examinations demonstrated resolution of the crepitus (over a 2-week period) and tube feedings were instituted without incident. The patient was subsequently discharged to a nursing care facility. CASE 2
An 88-year-old woman with a history of severe dementia was admitted to the hospital with infection and malnutrition. Given the inability to obtain adequate caloric intake by the oral route, a PEG tube was recommended as the best alternative for long-term enteral feeding. No contraindications to PEG placement were present and esophagogastroduodenoscopy at the time of tube placement was normal. The PEG tube was placed by the double endoscopic "pull" method as described by Gauderer et al. 2 At the point of maximal light transillumination and finger indentation, a needle stab was made into the stomach, with uneventful placement of the PEG tube, through a I-em skin incision. Immediate repeat endoscopy confirmed proper positioning of the tube which was secured into place. Peri-procedural GASTROINTESTINAL ENDOSCOPY
Figure 2. Radiograph of the upper chest and neck from patient 2. The arrows illustrate air in the subcutaneous tissues of the upper chest and neck.
antibiotics (cefoxitin) were administered and no immediate complications were evident. Tube feedings were initiated the following day without incident and were tolerated well. Seven days after tube placement, crepitus was noted along the anterior chest wall extending to the neck. Subcutaneous air was confirmed by plain films of the upper chest and neck (Fig. 2). The patient was afebrile and otherwise stable. The gastrostomy site was without erythema, induration, or drainage. Feedings were continued under close observation and proceeded without incident. The crepitus resolved 5 days following its onset.
DISCUSSION
Subcutaneous emphysema (SE) may arise from the forceful introduction of air through cutaneous and subcutaneous tissues, from soft tissue infection by gasproducing organisms, or via spontaneous disease-related, or iatrogenically induced rupture of an air filled cavity or viscus. 3 Subcutaneous emphysema of gastrointestinal origin is uncommon, but may result from spontaneous esophageal rupture (Boerhaave's syndrome), gastric or intestinal perforation secondary to ulcer disease, intestinal perforation secondary to diverticulitis, neoplastic disease, inflammatory bowel disease, infectious causes, and foreign body perforation. 4 Subcutaneous emphysema has been reported following a variety of endoscopic procedures, including esophagogastroduodenoscopy with perforation of a piriform sinus,5 colonscopy,6 colonoscopic polypectomy 7 and endoscopic sphincterotomy. 8 Subcutaneous emphysema following PEG placement is apparently uncommon. Our two cases bring to five the number of patients reported in the literature. Orchard and Barlow9 reported SE six days following PEG placement. A benign course (3 weeks to resolution) ruled out infection with gas-producing organisms as a cause. Bronner lO reported crepitus and VOLUME 37, NO.3, 1991
SE in a patient following inadvertent endotracheal tube placement into the esophagus 24 hours after uneventful PEG tube placement. Steffes et al.l! reported one patient who developed SE 5 days postprocedure without signs of infection. SE has also been reported following percutaneous gastrostomy by radiologic means12.13 and following surgical jejunostomy.14 Pneumatosis intestinalis has been noted with 14 and without SE 15 following surgical jejunostomy. Benign subcutaneous emphysema (BSE) must be distinguished from necrotizing fasciitis which has been observed following PEG placement.16-20 BSE presents hours to days following tube placement (range, 7 hours to 7 days in the five cases reported). An early presentation of crepitus (less than 48 to 72 hours postprocedure) seems to be more characteristic of BSE than necrotizing fasciitis. Although the initial presentation of necrotizing fasciitis may be insidious, the first manifestation is one of high fever (2 to 3 days post-tube placement) followed by erythema, induration, purulent drainage, and crepitus at the tube exit site, culminating in sepsis and clinical deterioration. High fever associated with signs of an infected gastrostomy site are not manifestations of BSE. BSE observed soon after percutaneous gastrostomy probably results from the dissection of intragastric air during the procedure through the subcutaneous tissues at the tube exit site. Insufflation of air via the endoscope may be an important contributing factor. Intraluminal pressures greater than 70 mm Hg (95 em H 20) may be seen with endoscopic air insufflation,21 whereas soft tissue pressures are only 5 em of H 20. 22 BSE that develops remotely following a PEG procedure is likely due to a large pressure gradient between the gastric lumen and subcutaneous tissues that is maintained by normal gastric contractile activity.22 This is especially true during vigorous abdominal wall contractions as seen with coughing and retching (P. J. Kahrilas, personal communication). Conceivably, snug placement of a PEG tube will not allow air to escape to the atmosphere via the gastrostomy site, thereby forcing a dissection of air into the subcutaneous space. Prevention of this entity requires an alternative route for drainage of intra-gastric air. A generous skin incision made at the time of tube placement has been advocated as a preventative measure for the development of both BSE and local infection.9.16.23 A patulous skin incision allows for drainage of intra-gastric air and fluid out the tube exit site versus dissection through subcutaneous tissues. This is necessary until sufficient scarring of the tract occurs, thereby preventing leakage of air underneath the skin. Absence of intraperitoneal or subcutaneous infection suggests the diagnosis of BSE. Once diagnosed, 375
the only treatment required is that of observation. Tube feedings can be continued once the diagnosis is certain. Antibiotics are not routinely necessary unless signs of infection become evident. Necrotizing fasciitis, however, requires aggressive surgical and medical therapy. Continued observation of the patient with BSE for signs of infection is mandatory. Crepitus should resolve within 1 to 3 weeks after initial onset.
REFERENCES 1. Russell TR, Brotman M, Norris F. Percutaneous gastrostomy. A new simplified and cost-effective technique. Am J Surg 1984;148:132-7. 2. Gauderer MWL, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5. 3. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema; pathophysiology, diagnosis and management. Arch Interm Med 1984;144:1447-53. 4. Walker MJ, Mozes MF. Massive subcutaneous emphysema: an unusual presentation of jejunal perforation. Am Surg 1981;47:45-8. 5. Burstein FD, Colman MF. A dramatic complication of peroral fiberoptic endoscopy. Head Neck Surg 1985;8:28-30. 6. Lezak MB, Goldhamer M. Retroperitoneal emphysema after colonoscopy. Gastroenterology 1974;66:118-20. 7. Humphreys F, Hewetson KA, Dellipiani AW. Massive subcutaneous emphysema following colonoscopy. Endoscopy 1984;16:160-1. 8. Tam F, Prindiville T, Wolfe B. Subcutaneous emphysema as a complication of endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1989;35:447-9. 9. Orchard JL, Barlow J. Benign subcutaneous emphysema after percutaneous endoscopic gastrostomy. Gastrointest Endosc 1987;33:51.
376
10. Bronner MH. Percutaneous endoscopic gastrostomy and crepitus. Gastrointest Endosc 1987;33:270-1. 11. Steffes C, Weaver DW, Bouwman DL. Percutaneous endoscopic gastrostomy. New technique-old complications. Am Surg 1989;55:273-277. 12. Wojtowycz MM, Arata JA. Subcutaneous emphysema after percutaneous gastrostomy. Am J RadioI1988;151:311-2. 13. Wills JS, Oglesby JT. Percutaneous gastrostomy. Radiology 1983;149:449-53. 14. Cogbill TH, Wolfson RH, Moore EE, et al. Massive pneumatosis intestinalis and subcutaneous emphysema: complication of needle catheter jejunostomy. J Parenter Enter Nutr 1983;7:171-5. 15. Zern RT, Clarke-Pearson DL. Pneumatosis intestinalis associated with enteral feeding by catheter jejunostomy. Obstet Gynecol 1985;65(suppl):81S-3S. 16. Grief JM, Ragland JJ, Ochsner MG, Riding R. Fatal necrotizing fasciitis complicating percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:292-4. 17. Cave DR, Robinson WR, Brotschi EA. Necrotizing fasciitis following percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:294-6. 18. Person JL, Brower RA. Necrotizing fasciitis/myositis following percutaneous endoscopic gastrostomy. Gastrointest Endosc 1986;32:309. 19. Komia J, Rice HE. Necrotizing fasciitis and percutaneous gastrostomy. Gastrointest Endosc 1987;33:335-6. 20. Haas DW, Dharmaraja P, Morrison JG, Potts JR. Necrotizing fasciitis following percutaneous endoscopic gastrostomy. Gastrointest Endosc 1988;34:487-8. 21. Kozarek RA, Sanowski RA. Use of pressure relief valve to prevent colonic injury during colonoscopy. Gastrointest Endosc 1980;26:139-42. 22. Quigley JP, Brody DA. A physiologic and clinical study of the pressure developed in the digestive tract. Am J Med 1952;13:7381. 23. Ponsky JL. PEG: no minor surgery [Editorial]. Gastrointest Endosc 1986;32:300-1.
GASTROINTESTINAL ENDOSCOPY