Small-bowel perforation: a consequence of feeding jejunostomy.

postsurgical sustenance of very ill patients with a functioning small bowel. Postpyloric feeding through a jejunal tube is in wide practice and usually well tolerated. We report a case of smallbowel perforation related to a feeding jejunostomy tube. A 76-year-old female was evaluated for symptoms of pruritis, painless jaundice, tea-coloured urine and yellow stools. An ampulary carcinoma was found via endoscopic retrograde cholangiopancreatography (ERCP). A pancreatoduodenectomy was performed, with insertion of a feeding jejunostomy tube. On the seventh postoperative day the patient had painful abdominal cramps. Upon examination, her abdomen had tympany and severe tenderness in the right upper quadrant. Computed tomography of the abdomen and pelvis revealed marked thickening of the proximal small bowel distally near the jejunostomy site. We did an emergency laparotomy and found wall necrosis with perforation, 100 cm distal to the tube insertion (Fig. 1). There was no evidence of intestinal strangulation or arterial occlusion. The necrotic edges of her bowel were immediately resected and sutured. The pathology report documented transmural necrosis and enteral nutrition impacted in the lumen (Fig. 2). The patient’s further recovery was uneventful. The causative mechanism of this small-bowel perforation remains unclear, but the condition had many similarities to necrotizing enterocolitis, including systemic and mechanical factors. Hyperosmolarity, invasive bacterial overgrowth and massive bolus impaction were implicated for direct mucosal injury in this case, probably by intense local vasospasm, which could cause ischemic necrosis and perforation. In cases of small-bowel obstruction, tube feeding should be discontinued im-