Pneumoperitoneum After Percutaneous Endoscopic Gastrostomy: Does It Have Clinical Significance?

signs were observed in 5 (55.5%) patients, with fever reported in 4, abdominal tenderness in 4, and leukocytosis in 4. Two patients (22.2%) with moderate (2−4 cm) or large (>4 cm) pneumoperitoneum after PEG died from either pneumonia or septic shock. The authors concluded that the clinical course of pneumoperitoneum after PEG is not always benign and self-limited, and therefore a moderate or large pneumoperitoneum should not be ignored. Although there may be some differences in PEG method and clinical environments, the incidence of pneumoperito-neum after PEG tube placement varies from 4.7% to 55.6%. 6-9 However, cases of patients who experienced clinically significant signs of pneumoperitoneum such as fever, abdominal tenderness, or leukocytosis were rare in previous studies. 5,8 Wiesen et al. reported that in the absence of clinical symptoms , post-PEG pneumoperitoneum is of no clinical significance , and does not warrant further intervention. 2 In contrast , a retrospective study of 85 PEG patients reported that 5% of cases had evidence of pneumoperitoneum, including one insertion through the colon. 3 The authors concluded that pneumoperitoneum, even without peritoneal signs and symptoms, may indicate iatrogenic bowel injury and requires follow-up and further diagnostic studies. 3 Symptoms after PEG tube placement are important findings that suggest complicated pneumoperitoneum. However, the authors in the present study maintain that these clinically significant findings can be masked due to coexisting conditions, including the use of broad-spectrum antibiotics due to coexistent infection, altered mental status, and long-term sedation. Therefore, clinicians could have missed pneumoperitoneum Since its first description in 1980 by Gauderer et al., 1 per-cutaneous endoscopic gastrostomy (PEG) has become the method of choice for providing enteral access and nutritional support to patients who are unable to take oral feed-ings. 2 The PEG-associated mortality rate is about 0.5% and various complications have been known to occur after PEG placement, including skin-site infection, acute hemorrhage, hematoma, aspiration, and perforation. 3,4 Among these, unintentional perforation of the small bowel or colon is a major complication, and is associated with peritonitis and sepsis, which can be followed by septic shock and death if not diagnosed and treated promptly. 3 Pneumoperitoneum detected on plain chest radiograph may be a sign of this serious complication. 5 However, the air that is insufflated at the time of the PEG procedure by endoscopy and the air that enters the peritoneal cavity through a puncture site on the gastric wall can …