| 제목 |
Air Leakage as Cause of Pneumoperitoneum after PEG Tube Removal in Cervical SCI with ventilator |
| 소속 |
Pusan National University School of Medicine, Pusan National University Hospital, Department of Rehabilitation Medicine1, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Department of Rehabilitation Medicine2 |
| 저자 |
Myung Hun Jang1*, Sung Chul Huh2, Myung Hoon Moon2, Byeong-Ju Lee1, Myung Jun Shin1† |
Introduction
Pulmonary and gastrointestinal (GI) problems are a common comorbidity of cervical spinal cord injury (SCI). Pulmonary complication, such as respiratory failure, requiring tracheostomy and mechanical ventilatior occurs usually within a few weeks after injury. The initial GI problems after SCI and its management are also well documented. But, this case shows that uncontrolled aerophagia leads to air leakage in high cervical SCI supported by mechanical ventilator after percutaneous endoscopic gastrostomy (PEG) tube removal.
Case report
A 79-year-old man was diagnosed with C3-4 dislocation and immediate C3 tetraplegia ASIA A from slip and fall accident on June 2015. During his acute care hospitalization, PEG tube and tracheostomy tube were placed. He had been supported by home ventilator via a tracheostomy. Seven months after injury he was able to take a light diet and began to learn to breathe without the ventilator for gradually increasing periods. Mild paralytic ileus and aerophagia were observed during this period but it wasn’t worse. Because oral nutritional support was enough for maintaining general health condition and videofluoroscopic swallowing study test was normal, we removed the PEG tube. After then, abdominal distension was steadily worsening because of aerophagia and paralytic ileus. The patient's laboratory data remained normal and plain abdomen radiograph showed only gastric distension. Further radiologic studies were performed including chest computed tomography, barium esophagography, to find out the cause of abdominal distension. There were no abnormal findings such as tracheomalacia, tracheoesophageal fistula. Bronchoscopy also revealed a normal trachea and bronchus. During evaluation, he maintained progressive ventilator-free breathing for weaning from the ventilator. At 3 weeks post removal, he suddenly collapsed profoundly with a low blood pressure, rapid poor volume pulse and a markedly distended abdomen. Decubitus x-rays of abdomen displayed large amount of pneumoperitoneum (Fig. 1). Emergency surgical operation was performed to diagnose bowel perforation and repair it. But, any visible perforation was not noted on the surface of the stomach and bowel. There were only some inflammatory signs on the PEG tube removal site and surgical team repaired it. After surgery, nasogastric (NG) tube was inserted for gastric decompression and drainage. GI perforation occurred, but fortunately peritonitis didn't occur, because there was only small air leakage on the PEG removal site and he maintained supine position most of time.
Discussion
Aerophagia may be a frequent occurrence in patients with high cervical SCI when being weaned from ventilator. If PEG tube is scheduled to remove in high cervical SCI with ventilator, make sure to always check aerophagia in abdomen x-ray. Uncontrolled aerophagia must be corrected prior to PEG tube removal with proper procedures such as NG tube insertion to prevent unexpected complications. |
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Fig. 1 Large amount of pneumoperitoneum on a right lateral abdominal decubitus, after PEG tube removal.
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