Peritonitis after percutaneous endoscopic gastrostomy and jejunostomy: where there is smoke, there may not be fire

• Introduction
• Case report 1
• Case report 2
• Case report 3
• Discussion
• References

Extensive reviews have been published regarding complications arising from percutaneous enteral access and ways of managing them. However, few data are available regarding unnecessary clinical interventions resulting from misinterpretation of benign postprocedural findings. We present here three representative cases of negative surgical abdominal cavity explorations for presumed peritonitis after percutaneous endoscopic gastrojejunostomy and jejunostomy.

Introduction

Since their clinical introduction in the late 20th century, percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrojejunostomy (PEGJ), and direct percutaneous endoscopic jejunostomy (DPEJ) have become widely accepted techniques for providing enteral access in patients requiring long-term enteral nutritional support [1] [2]. Extensive reviews have been published on complications arising from percutaneous enteral access procedures. However, few data are available on benign postprocedural findings which, in case of misinterpretation, can lead to unnecessary clinical interventions [3].

The presence of intraperitoneal free air is a frequent, benign, and transient finding after placement of a PEG, PEGJ, or DPEJ [4]. If no signs or symptoms of peritonitis are present, the presence of pneumoperitoneum should neither preclude the starting of tube feeding nor lead to further diagnostic or therapeutic interventions. Patients with significant abdominal pain after stoma placement should be carefully evaluated. However, the abdominal pain should not be overinterpreted if clear signs of peritonitis are lacking. This is especially true for patients who have a history of chronic abdominal pain, such as patients with visceral hypersensitivity or chronic pancreatitis. We present here three representative cases of negative surgical abdominal cavity explorations due to presumptive peritonitis after PEGJ and DPEJ placement.

Case report 1

A 51-year-old woman developed symptoms consistent with postsurgical gastroparesis shortly after a laparoscopic Nissen fundoplication. The diagnosis was confirmed with a gastric emptying study. The patient had persistent nausea and vomiting and was unable to take in adequate oral nutrition. No symptomatic improvement occurred with prolonged medical therapy. She was referred for DPEJ placement to provide nutritional support.

A 20-Fr DPEJ tube (Boston Scientific, Natick, Massachusetts, USA) was successfully placed using the standard pull technique, without immediate complications. After the procedure, the patient complained of severe, diffuse abdominal pain and nausea. On physical examination, the abdomen was found to be tympanic and diffusely tender to palpation, but normal bowel sounds were present. Continuously infused tube feeding of a standard polypeptide formulation at 30 - 40 ml/h was initiated. Her pain remained poorly controlled with narcotic pain medication.

On the second day after the procedure, the patient was still complaining of abdominal pain. Mild rebound tenderness was found on the abdominal examination. She had no fever, and the white blood cell count was persistently normal. Tube feeding was withheld and an abdominal computed tomography (CT) scan was obtained. The CT demonstrated free air in the peritoneum and dilated loops of small bowel, but no abdominal free fluid (Figure [1]). There was a misreading of free air in the retroperitoneum; this air collection was actually located in Morison’s pouch. A surgical consultation was obtained, and an emergency exploratory laparotomy was performed. No leakage, duodenal injury, or intestinal perforation was found intraoperatively. Postoperative recovery was complicated by persistent pain and severe nausea and vomiting, which resolved after the pain medication was discontinued. Thirty days after the procedure, the patient was tolerating jejunal tube feeding, but had persistent midline abdominal pain and had not returned to work.

Case report 2

A 29-year-old woman with a history of Crohn’s disease, fibromyalgia, and status post cholecystectomy was admitted to the hospital with a recurrent episode of acute pancreatitis. She complained of severe abdominal pain radiating to the back, with associated nausea and vomiting. On pancreatography, an irregular pancreatic duct with ectatic side branches, consistent with chronic pancreatitis, was noted. One week later, there was no significant clinical improvement. The patient was referred for PEGJ placement for nutritional support and pancreatic rest.

A 24-Fr/12-Fr PEGJ tube system (Boston Scientific) was successfully placed using an over-the-wire technique [5]. After the procedure, the patient’s abdominal pain increased. She developed a transient fever (4 h to 39.1 °C); on the abdominal examination, tenderness to palpation and mild distension were noted, but no rebound tenderness. Normal active bowel sounds were present, and the PEG site was clean. A complete blood cell count was obtained and showed a mild increase in the white blood count from 9400/l to 13 200/l (4800-10 800/l). An abdominal CT was obtained. It revealed a well-positioned PEGJ tube system without leakage of contrast from the stomach; however, a large pneumoperitoneum was present (Figure [2]). The decision was taken to carry out an urgent exploratory laparoscopy. No peritoneal abnormality was seen. The stomach was adherent to the abdominal wall, and no leak was found. The patient was discharged 5 days after surgery tolerating small amounts of clear fluids orally and using the J-tube for nutritional support, with good pain control.

Case report 3

A 46-year-old woman with chronic alcoholic pancreatitis had undergone Puestow drainage and Whipple resection of the pancreas. She had been treated with chronic narcotics as an outpatient, but continued to complain of increasing pain, mainly after oral intake. She was admitted to the hospital for pain assessment, hydration, and nutritional support. She was referred for DPEJ placement both for nutritional support and pancreatic rest.

A 20-Fr DPEJ tube (Boston Scientific) was successfully placed using the pull technique. When the tube feedings were initiated, the patient complained of diffuse abdominal pain, but no nausea or vomiting. She was afebrile. The abdomen was soft but distended and diffusely tender to palpation. Normal active bowel sounds were present. The DPEJ site had no drainage and was not erythematous. Laboratory evaluation revealed a normal white blood cell count. A contrast study through the DPEJ tube confirmed that it was in an intrajejunal location and showed no leakage. On the sixth day after the procedure, the patient still had abdominal pain and abdominal distension; tube feedings were withheld and an abdominal CT was obtained. It demonstrated intraperitoneal free air and an ill-defined fluid collection with air bubbles just below and surrounding the DPEJ tube (Figure [3]).

These radiographic findings led to an exploratory laparotomy. No perforation, leakage, or abscess was discovered. A segment of small bowel, including the entrance of the DPEJ tube, was resected and a surgical J-tube was placed. Pathological examination of the resected jejunum revealed no evidence of significant tissue inflammation and an intact DPEJ entry site. Adherent small-bowel loops from previous surgical procedures near the DPEJ small-bowel entry site had resulted in misinterpretation of the abdominal CT scan by the radiologist as showing a extraintestinal fluid collection. The postoperative period was complicated by severe abdominal pain and prolonged ileus, which required narcotic pain medication and the use of parenteral nutritional support. The patient was discharged 30 days after surgery using the J-tube for feeding.

Discussion

Placement of a PEG, PEGJ, or DPEJ tube should be considered in patients with a functional gastrointestinal tract who are unable to consume enough calories to meet their metabolic requirements. Percutaneous endoscopic jejunostomy tubes can be placed endoscopically with two different techniques: placing a PEG tube with a separate jejunal extension (PEGJ) or placing a jejunal tube directly into the small bowel (DPEJ). Both of these techniques often require the use of a pediatric colonoscope in order to place the jejunal tube in the proper position successfully. The procedures have high reported success rates, with a low risk of major complications [3].

Pneumoperitoneum is a common, benign radiographic finding after PEG, PEGJ or DPEJ [4] [6] [7]. It has been reported to occur in 23 - 56 % of PEG procedures and should not be regarded as a complication unless signs of peritoneal inflammation are present. Postprocedural pneumoperitoneum is related to the endoscopic technique itself. Insufflation of the stomach or small bowel with air is necessary to achieve gastric or small-bowel distension, and the air can leak around the gastric or small-bowel needle access puncture site.

A recent retrospective review of the frequency and significance of post-PEG pneumoperitoneum reported that it occurred in only 8.6 % of patients (10 of 119) [8]. The authors stated that this low incidence might have been associated with the retrospective nature of their study. However, of the ten patients with pneumoperitoneum in the series, two underwent exploratory laparotomies for suspected peritonitis. Our own center’s unpublished data suggest that pneumoperitoneum occurs in approximately 70 % of patients after PEG, PEGJ, or DPEJ procedures.

Peritonitis after stoma placement is uncommon and is usually not related to the procedure itself. It often occurs after removal of the feeding tube inadvertently before the gastrocutaneous or enterocutaneous tract has matured. The other possible causes of peritonitis after PEG, PEGJ, or DPEJ include leakage around the percutaneous feeding tube secondary to poor tract formation or perforation of the gut during the procedure.

Diffuse abdominal pain after PEG placement should not be ignored, as it may be an early sign of peritonitis. However, abdominal pain and pneumoperitoneum following stoma placement are very common. Only obvious clinical signs of peritoneal inflammation, including abdominal rebound tenderness, persistent fever, and a significantly elevated white blood cell count, with unequivocal radiographic imaging findings, should lead to consideration of abdominal surgical exploration. If gastric or small-bowel leakage or perforation is suspected after enteral access, instillation of water-soluble contrast through the tube is the best diagnostic tool, as it confirms the tube’s location and determines whether a leak is present.

The first patient reported above underwent DPEJ placement and developed diffuse abdominal pain and pneumoperitoneum, but no other signs of peritonitis. There was an image misreading of retroperitoneal free air by the radiologist. The second and third patients underwent PEGJ and DPEJ placement, respectively; both had a previous history of chronic abdominal pain. In the second case, the presence of abdominal pain, transient fever, and a mild increase in the serum white blood cell count was misinterpreted as corroborating a diagnosis of peritonitis and led to a surgical intervention. No contrast study was obtained through the feeding tube to determine its location or to diagnose gut leakage or perforation. In the third case, an ill-defined air-fluid collection on the CT scan was interpreted as an intra-abdominal abscess and led to an unnecessary abdominal surgical exploration. The CT was difficult to interpret because of multiple previous abdominal operations. No contrast study through the feeding tube was obtained.

In summary, peritonitis is a very rare complication after PEG, PEGJ, and DPEJ. The finding of pneumoperitoneum with abdominal pain should be investigated. An abdominal surgical exploration should only be considered if there are obvious signs of peritonitis, including abdominal rebound tenderness, persistent fever, and a significantly elevated white blood cell count, in combination with an abnormal contrast radiographic study through the feeding tube.

Competing interests: None

References

• 1 Gauderer M W, Ponsky J L, Iznat R J. Gastrostomy without laparotomy: a percutaneous endoscopic technique.  J Pediatr Surg. 1980;  15 872-875
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• 8 Dulabon G R, Abrams J E, Rutherford E J. The incidence and significance of free air after percutaneous endoscopic gastrostomy.  Am Surg. 2002;  68 590-593
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S. Faias, M. D.

Medical University of South Carolina Digestive Disease Center

Suite 210 · Clinical Science Building · P.O. Box 250 327 · 96 Jonathan Lucas Street · Charleston, SC 29425 · USA

Fax: +1-843-792-4184 ·

Email: sandrarfaias@hotmail.com

References

• 1 Gauderer M W, Ponsky J L, Iznat R J. Gastrostomy without laparotomy: a percutaneous endoscopic technique.  J Pediatr Surg. 1980;  15 872-875
  CrossrefPubMedSearch in Google Scholar
• 2 Ponsky J L, Aszodi A. Percutaneous endoscopic jejunostomy.  Am J Gastroenterol. 1984;  79 113-116
  PubMedSearch in Google Scholar
• 3 McClave S A, Chang W K. Complications of enteral access.  Gastrointest Endosc. 2003;  58 739-751
  Search in Google Scholar
• 4 Gottfried E B, Plumser A B, Clair M R. Pneumoperitoneum following percutaneous endoscopic gastrostomy.  Gastrointest Endosc. 1986;  32 397-399
  PubMedSearch in Google Scholar
• 5 Duckworth P F jr, Kirby D F, McHenry L. et al . Percutaneous endoscopic gastrojejunostomy made easy: a new over-the-wire technique.  Gastrointest Endosc. 1994;  40 350-353
  PubMedSearch in Google Scholar
• 6 Wojotowycz M M, Arata J A, Micklos T J. et al . CT findings after uncomplicated percutaneous gastrostomy.  AJR Am J Roentgenol. 1988;  151 307-309
  PubMedSearch in Google Scholar
• 7 Pidala M J, Slezak F A, Porter J A. Pneumoperitoneum following percutaneous endoscopic gastrostomy: does the timing of panendoscopy matter?.  Surg Endosc. 1992;  6 128-129
  PubMedSearch in Google Scholar
• 8 Dulabon G R, Abrams J E, Rutherford E J. The incidence and significance of free air after percutaneous endoscopic gastrostomy.  Am Surg. 2002;  68 590-593
  PubMedSearch in Google Scholar

S. Faias, M. D.

Medical University of South Carolina Digestive Disease Center

Suite 210 · Clinical Science Building · P.O. Box 250 327 · 96 Jonathan Lucas Street · Charleston, SC 29425 · USA

Fax: +1-843-792-4184 ·

Email: sandrarfaias@hotmail.com