Massive Pneumoperitoneum And Pneumoretroperitoneum After Gastroscopy

Massive Pneumoperitoneum

Pneumoretr operitoneum

After Gastroscopy Report of a Case and Review of the Literature

and

DAVID KATZ, M.D.* a n d SYDNEY SELESNICK, M. i ) .

G ASTIgOSCOPISTS HAVE STUDIED the relative risk of gastroscopy by quest.ionnaire14, .21 and by screening individual series in the com-

pilation of excellent reviews/~, ~L The serious complications of gastroscopy have consisted principally of perforation of the pharynx and esophagus. Perforat ion of the s tomach seems to be relatively innocuous. The incidence of perforations and their locations are summarized in Table 1. There is some duplication of cases in these reports. Conse- quent.ly, the perforation of the je junum reported by Rumbal l ~ is noted in three of the tabulations, as are the collected cases from several large published series J, 9. H. ~, 2.,, ,,:~, ~5, ._,s

I t appears tha t the risk of perforation in flexible gastroscopy is ap proximately t in 1000 examinations. This figure may be exaggerated, since m a n y reports were submi t ted after a perforation occurred and only the examinations to the t ime of perforation were reviewed. Itow- ever, it will be seen tha t several of the gastric perforations were asymptomat ie and discovered by chance, suggesting tha t some gastric perforations may go unnoticed.

Perforat ion of the pharynx or esophagus is a catastrophe requiring immediate surgical intervention. Perforat ion of the stomach rarely requires in tervent ion unless signs of peritonitis develop: it has been termed a remarkably benign accident t) 3 Pahner/~ A review of the

From the D e p a r t m e n t of Medicine and Surgery, VA Hospital , West Haven, Cram., and YMe Univers i ty School of Medicine, New Haven, Conn.

* Present address : Gas t ro in tes t ina l Clinic, Mt. Sinai Hospital , Xew York City. Reviewed in the Veterans Admin i s t r a t ion and publ ished wi th the tipproval of tt,e

Chief Medieal Director . The s t a t emen t s and conclusions published by the .mthors are a result of the i r own s tudy :rod do not neeesstH.ily reflect the opinion or policy of lhe Veterans Adminis t ra t ion .

AMERICAN JOURNAL OF 512 DIGESTIVE DISEASES

Massive Pneumoperi toneum after Gastroseopy

] ' A B L E 1. I n c i d e n c e o f G a s t r o s c o p i c P e r f o r a t i o n s

Perf. of Authors Year No. p h a r y n x or Perf. of O the r % per-

exams esophagus s t o m a c h si tes fora t ion

Sehindler 27 1940 22351 1 (1) ~ 8 (0) I b (0) .044 ,Jones et al. TM 1951 49000 50 (21) 9 (1) 0 .119 Pa lmer ~1 1954 2,5077 17 (8) 9 (0) 1 b (0) .108 H u n t e r ~.~ 1955 29986 14 (7) 17 (1) 1 h (0) .110

" Figures in pa ren theses show mor t a l i t y . ~' l l umba l l ' s 2~ case.

published eases of perforation tends to confirm this view. On occa- sion4.7. ~ . . , ~. 2.~. 3~ laparotomy immediate ly after a supposed perforation has revealed no gastric tear. Most eases of perforation diagnosed on the basis of free air in the peritoneal cavi ty have been t reated conservatively.i , 3. ~. 1~. 19, 23. _~6, 33.34 Indeed the gastric perforations which have been detectable as rents in the s tomach wall a t surgery have been rare.~. 2s, ~.~

It is the purpose of this report topresent a ease of pneumoperi toneum, pneumoretroperi toneum, and pneumomedias t inum detected following gastroseopy, to review the literature, and to discuss the mechanism of production of the roentgenographie findings. This ease represents the first recognized perforation in 1314 gastroseopies and 221 flexible esophagoseopies performed on this service.

CASE REPORT

F.M., a 62-year-old white, male laborer, was admitted to the Pulmonary Disease Service of the West Haven VA Hospital on September 9, 1955, because (~f hemoptysis. A chest film taken prior to admission was suggestive of tuberculosis. The only symptom related to tuberculosis was fatigue. The patient complained of "heartburn" all of his adult, life. Two weeks prior to admission he developed a sore tongue. There were no additional gastrointestinal symptoms.

Physical examination revealed a markedly cachectic, pale, white male who appeared chronically ill. Rectal temperature was 100.8 ° F. Cheilosis was noted. The tongue was beefy red and smooth and had papillae only at the borders. The trachea was deviated to the right of the midline. Mild dorsal kyphosis was present. Changes on percussion and many rales were noted over both hmg fields. Deep tendon reflexes and vibratory sense were normal. The remainder of the physical examination was not significant.

The positive laboratory findings included a hemoglobin of 9.5 Gm. and hematocrit of 32 per cent, achlorhydria both before and after histamine stimulation, stools slightly positive (guaiac test.) for occult blood, and sputum positive for acid-fast bacilli.

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Roentgenograms of the chest revealed bilateral cavitat ion and far-advanced tuberculosis. Oll September 13, 1955, bar ium enema disclosed diverticulosis of the sigmoid. A gastrointestinal series on September 21, 1955, revealed a defect along the lesser curvature of the s tomach (Fig. 1.). The radiologist commented that "despite the normal appearance of the stomach, [I] would suggest gastroscopic exam to be sure 11o abnormal i ty is present o,1 direct visualiza- t ion."

Gastroscopic Examination

On September 28, 1955, a gastroscopic examination was undertaken. The pat ient was prepared with sodium phenobarbi tal 100 rag. intranmscularly, morphine sulfate 10 rag. subcutaneously, and atropine sulfate 0.4 rag. subcutaneously. The pharynx was anesthetized with 8 cc. of 1 g Benadryl solu- tion (p.o.) according to the method described by Selesnick a~ and used routinely on this service. Gastric aspiration was not done.

The Eder-Chamberl in gastroscope was introduced with ease and passed to the cardia where some resistance was encountered. After a short pause, gentle pressure was exerted and the instrumeut passed into the stomach. A small initial amount of air was instilled. A round view of the stomach could not be obtained. I t seemed as if a whitish-pink membrane was covering one third of the objective, in half-moon fashion, from the pat ient ' s right. This field defect persisted, hi the remaining two thirds of the field, atrophic nmcosa, with vascularization, was noted. The stomach was never expanded fully with introduction of air, yet the pat ient did not belch. The instrument could not be advanced further than the proximal pars media. A second observer (S.S.) confirmed these findings. On withdrawal the instrument seemed to be held up at the cardia. After a brief delay it was withdrawn easily. The entire examination had taken 5 minutes.

The patient had experienced no pain and, except for an inability to belch, felt well. He returned to his ward and ate supper. At 9:00 P.xL, 7 hours after the examination, the pat ient complained of a feeling of distention and, again, of an inability to belch. He was afebrile and his vital.signs were stable. The abdomen was markedly distended and liver dullness was obliterated. A tyro- panitic percussion note was detectable in all quadrants. There was no ten- derness. There was no subcutaneous emphysema or mediastinal crunch

A Levin tube was passed and a small amount of curdled milk removed. The pat ient felt comfortable immediately and commented tha t his feeling of dis- tension had been relieved. Roentgenograms (Figs. 2 and 3) revealed massive pneumoperi toneum and pneumoretroperi toneum. Some air was also detected about the aorta in the mediast inum (Fig. 4.).

Penicillin and s t reptomycin were started. Because the pat ient had no dis- comfort needle aspiration of the pneumoperi toneum was not a t tempted. The Leviu tube was kept in place for 5 days. On the sixth day Lipiodol s tudy revealed no perforation of the esophagus and the pat ient was again fed orally.


Massive Pneumoperi toncum after Gastroseopy

There had been no febrile response and, except for a transient leukoeytosis of 14,000 white blood cells/eu, cm. on the day after gastroseopy, the course was benign. Antibiotics were stopped after 6 days. Distention of the abdomen was not clinically detectable 7 days after gastroscopy. However, a roentgeno- gram on Xovember 2, 35 days after perforation, revealed a small residual amount of subdiaphragmatic air.

DISCUSSION

Pneumoper i toneum as a complication of gas t roseopy has been re- por ted seventeen times ~, 3, 4, ~. 7, s, 11. ~, is. ~9, .~3, 26, ~9, ~3, ~,, a~ The exact mechanism of its product ion remains unproved. I t seems probable tha t except for the rare ease ~, s, 2~ there is no actual tear in the wall of the stomach. Various fascinating possibilities have been discussed. A review of the findings of several eases m a y present a dynamic view of the actual occurrences.

Myhre and Wilson 's s tudied 119 pat ients by roentgenography 24 hours after gastroseopy, in the erect posteroanter ior position. All were asymptomat ie . In two instances they discovered a line of decreased densi ty around the gastrie air bubble which they interpreted as evidence of interstitial gastxie emphysema. If this s tudy represents the usual situation, the actual incidence of this phenomenon may be on the order of 2 per eent of all gastroseopies. Apparen t ly no fur ther progress of air occurs in the ordinary ease, for proved pneumoperi toneum is rare, and the presence of only 5 ee. of air in the abdominal cavi ty may be detec ted roentgenographieally. -'° No other studies of this type have been undertaken.

There have been various explanations of the mechanism of introduction of air through the gastrie mueosa. Apparent ly interstit ial gastric emphysema need nor be a s tep in the formation of pneumoper i toneum. In Sehindler's ease -~9 no pathology could be detec ted at surgery. He postula ted that air introduced into the s tomaeh had caused a rent through all layers of the s tomach wall. The rent had quickly closed, he thought. Chamberlin, 7 after a review of microscopic sections obta ined at surgery, suggested tha t air had been forced into the perineural lym- phatics, since these were dilated. His pat ient had an ulcer and the possi- bil i ty tha t air had passed through the bed of the ulcer was mentioned. Fierst et al./whose pat ient had a malignant ulcer, suggested tha t air might have passed through the ulcer and then along perivaseular sheaths. One pat ient of the two presented by Asher and Cohen ~, who had a malignancy on the posterior wall, developed pneumoper i toneum. It has been shown tha t air may pass through normal mucous mem- branes wi thout overt tears. Brown and Fine ~ recorded a ease of diffuse

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Katz & Selesnick

interstitial emphysema after a double contrast enema, when no perforation of the rectal wall was detected. Air had passed into and through the rectal wall to the retroperitoneal space in large amounts, there be- ing no residual tear apparent on careful examination.

It. would seem that one other mechanism by which air might, be introduced should be mentioned. In five previous ease reports and in the one presented here, some difficulty was encountered negotiating the cardia. An esophageal tear at t.he cardia on the lesser curvature side would permit air to be introduced both into the peritoneal cavity and retroperitoneally. In the ease presented, the half-moon-shaped membrane covering the third of the field on the patient's right would have been in the correct position for such a tear. Franklin, 1° however, men- tions only one recorded case of an esophageal tear opening into the peritoneum or peritoneal cavity. The usual course of esophageal perforation is not benign even at the esophagoeardiac junction. 3-~

Once air has found its way into the wall of the stomach its path can be traced. At surgery Charnberlin 7 described emphysematous blebs along the lesser curvature of the stomach. Air had also progressed within the greater and lesser omentum, as it had in the eases of Gilbert et a l . , H Fierst et a l . , s and Ylvisaker and Myhre. a5 Rents were noted in the omentum, explaining the ultimate pathway by which air reached the peritoneal cavity. In Chamberlin's ease the air had also dissected through the gastrohepatie ligament and was found in the aortic sheath. By this route it traveled retroperitoneally and then into the medias- tinum. The route detailed confirms the experimental work of Macklin, 16 who working with eats demonstrated this course from above downward. Pneumoperitoneum is seen in therapeutic pneumothorax ~7 as is pneumomediastinum in therapeutic pneumoperitoneum, 2 the air passing over the same routes postulated in this ease. Pneumoperitoneum may also occur spontaneously after the rupture of an emphysematous bulla of the lung. .2

Unless signs of peritoneal irritation occur, therapy of pneumoperitoneum after gastroseopy is conservative. 2~ Bergh et a l . ~ and Schind- ler a° mention the relative danger of gastrie perforations in patients with aehlorhydria. Sehindler stressed the advisability of surgery for pneumoperitoneum in aehlorhydria. The patient here did well in spite of achlorhydria. The mechanism of the perforation with the absence of an overt tear and no peritoneal soilage would explain the benign course and the advisability of conservative therapy. Rappaport and Finkel ~a and Palmer '-'~ suggest aspiration of the peritoneal air. Unless there is symp- tomatology related to the pneumoperitoneum, this measure seems un-

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M a s s i v e P e n u m o p e r i t o n e u m a f t e r G a s t r o s e o p y

warranted since absorption is inevitable. The case reported by Rappa- port and Finkel was in extremis prior to aspiration, but responded immediately upon reInoval of air. Gastric aspiration for five days has been suggested ~ but eases have done well without this therapy. 1, 3, a~ Antibiotics are indicated as a prophylactic measure. The prognosis in pneumoperitoneum after gastroscopy is excellent.

SUMMARY

1. The risk of perforation in flexible gastroscopy has been reviewed. 2. A case of pneumoperitoneum, pneumoretroperitoneum, and

pneumomediastinum occurring after gastroseopy has been reported. Treatment was conservative and the course benign.

3. A review of the cases of pneumoperitoneum in the literature and the probable mechanism of their production has been presented. An additional possible etiologic factor of tear at. the esophagogastric junction has been suggegted.

4. Treatment of the condition has been discussed. Achlorhydria is not considered a contraindication to conservative therapy.

5. The prognosis of pneumoperitoneum after gastroscopy, treated conservatively, is excellent..

175 Craw Ave. Mt. Verno~h N. Y.

R E F E R E N C E S

1. ASHER, L. M., and COHEX, S. Gastroscopic perforation of esophagus and stomach; report of 3 ea,ses. Gastroenterology 12: 966, 1949.

2. BAxYAL A. L., and J~-RGEXS, G . H . Mediastinal emphysema as a complication of artificial pneumoperitoneum, J. Thoracic Surg. 8: 329, 1939.

3. BERGH, G. S., BOWERS, W. F., and ~,VANGENS'I'EISN, O . H . Perforation of gastrointestinal tract: Experimental stud)" of factors influencing the development of peritonitis. Surgery 2: 196, 1937.

4. BEJ~K, J. ]':. Pneumoperitoneum after gastroseopy without evidence of perforation at laparatomy 14 hours later. Gaslroenlerology 6': 218, 1946.

5. Boox, T . H . Accidental perforation during gastroseopy. Lancet 1: 651, 1951. 6. Beowx, S., and Fixs, A. Diffuse emphysema following a double contrast enema.

Radiologq 37: 228, 1941. 7. CHA.~B~LIX, D.T . Pneumoperitoneum following gastroseopy apparently without

perforation; report of ease. New England J. Med. 237: 843, 1947. 8. FIERST, S. M., Romxsox, H. M., and LASAGX.~, L. Interstitial gastric emphysema

followin~ ~astroseopy; its relation to syndrorne of pneumoperitoneum and gen- eralized emphysema with no evident perforation, Ann. Inl. Med. 34: 1202, 1951.

9. FLm'CHm~, C. M., and JOXES, Y.A. The risks of gastroseopy with flexible gastroseope. Brit. M. J. 2: 421, 1945.

10. FRAXKLrX. R . H . Suroery of lhe Esophagus. Baltimore, Williams & Wilkins 1952, p. 65.

11. GTLBEr~T, R. L., KXICHT, W. A., JR., and DALTON', A . R . Pneumoperitoneum fol lowing gastroscopy without demonstrable perforation at laparotomy. Gastro- enteroIogg, t2: 139. 1949.

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12. tItXK~'~L, C. 1,. Spontatleous l)lleumot)eritoneunl wi thout visceral perfor-ttion, lm. J. Ifoet~tge~tol. ,~3: 377, 1940.

13. HtXTER, R . C . Gast roseopy and delayed rupture of tile spleen; a review and report of a possible case. Gastroe,~terology 29: 898, 1955.

14. Joxes, F. A., el al. Risks of gastroscopy: Survey of 49,000 examinat ions . Lancet 1: 647, 1951.

15. LICttSTEIN, J., and WHAltTOX, G . K . Gas t roseopy followed by pneumol)er i toneum with no discernible lesion at, l aparo tomy three hours later. Gastroet~lerology I1: 127, 1948.

1G. ~IACKLIN~ C . C . Pneumothorax with massive collapse from exl)erimentaI over in- flt~tion of the hmg substance. ('anad. M. A. J . 36: t89, 1937.

17. 5IACKLIN~ .'~,I. T., and 5IACKI.IN, C. C. Mal ignan t in te rs t i t ia l emphysema of the hmgs and med ias t inum as an i m p o r t a n t adu l t complicat ion in many respi ra tory diseases and o ther condi t ions : An in te rp re ta t ion of the elinieat l i t e ra tu re in the light. of l abora to ry exper iment . Medicine 23: 281, 1944.

lS..-~[YHRE, J., and WH.sox, J. A. S tudy on occurrence of pneumoper i toneum after gas t roseopy and obserwmee of in te rs t i t ia l emphysema of s tomach. Gash'oe,~leroIogy t1: 115, 1948.

19. NnLsox, R. S. Pneumoper i tone tml following gast roseopy wi th spontaneous recovery on conserva t ive therapy. Gastroenterology 2~: 267, 1953,

20. PAIXE, J. R.. and IlmLEn, L . G . I )neumoper i toneum in perforati(ms of lhe GI l raet . SuWery 2: 351. 1938.

21. I)ALXIEn, E. 1). The risks of peroral endoscopy. ( ' . S. :t cmed Forces M. J. 5:974. 1954.

22. PAuL, W. 1)., and .\xT~:s, 1';.t1. Per fora t ion of esophagus caused by f lexiblegastro- scope, e'tse report . Rev. Gastroenle~'ol. 13: %, 1946.

23. RAPPAPORT, E. M., and FIXKEL, S. -Massive lmemnoper i toneum during gastroseopy t rea ted by needle pune lure of the :d)domen. New Engla~d J. Med. 2~9: 195, 1953.

2-1. I{U_~BALL, J. M. Perfora t ion of j e j unum dur ing gastroseoi)ie examinal ion of re- seeted stoinaeh. ,] . .I .M..t . 113: 2053, 1939.

25. SCHIFF, L., and StlAPIR(), X. Per fora t ion of the stoma(!h with the flexible gaslro- s cope :Case report . Am. J. Digest. Dis. 8: 260, 1941.

2(). SCHIFF, g., STEVENS, 1{. J., alld G()ODMAN, S. Pnenmoper i toneum following the use of the flexible gqstroscope. :Imp. I~l. Med. 1.4: 1283, 1941.

27. SCmNI)LER, R. Resul ts of quesl ionmtire on fatal i t ies in g'tstroscopy. .Ira. J . Digest. Dis. 7: 293, 1940.

2N. SCHINDLER, I1. l lui)ber finger of the gast:roseope: A warning. Ga.slfoetderolo.q!t 13: 473, 1949.

29. SCH[NDLER, R. Pass'~ge of air th rough gastric wall din'in8 gastroseopy, with no wound demonst rab le three hours later . Gastroenterology 5: 34, 1945.

30. SCm.XDLER, II. Gas t roseopy: The Endoscopic S tudy of Gastr ic Pa thology (ed. 25. Chicago, Univ. Chicago Press, 1905. pp. 93-95.

31. SELgSXICK, S. Pharynge:d anes thes ia for gastroscopy and esophagoseopy: A new simplified technique. Gastroenterology 17: 515, 1951.

32. S1,Excm~, F. M., and Moxm)~:, L . S . Gastroscopie perforat ion of the distal esopha gus: Is air insufflation a factor? Gast~'oenlerotofly 29: 889, 1955.

;~. VILL_~REAI.. 11. Pneumoper i toneum following gastroseol)Y with spontaneous recovery; report of a ease. Gaslroenterology I5: 364, 1950.

34. WiLsox, J. A., and HAAS, ~,W. I~. Pneumoper i toneum with si)ontaneous recovery. following use of flexible gastroseope. Gastroe,~leroIogy 10: 731, 1948.

35. YLVISAKER, tl . S.. and .~IYHRI% J. Mam~gement of pneumoper i loneum af ter gas- tros('ot)y. G~sle,e~decolog!! I8: 463, 1951.


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Massive Pneumoperitoneum And Pneumoretroperitoneum After Gastroscopy