Pneumoperitoneum after Percutaneous Endoscopic Gastrostomy

A 68-year-old male was admitted to the Gastroenterology department for elective percutaneous endoscopic gastrostomy (PEG) tube placement. The patient had neurologic dysphagia secondary to amiotrophic lateral sclerosis, recurrent low respiratory tract infections and was receiving nutricional support from a nasogastric tube since the previous four months. A 20Fr PEG tube (Covidien®) was placed by ‘‘pull-onstring’’ technique, with the external bumper on the 3.5 cm mark. There were no complications during the procedure or after a 24-hour surveillance period. Enteral feeding with the PEG tube was successfully started. Oral and written educational support was provided to the caregivers. Four days after PEG tube placement, the patient developed abdominal distension and dyspnea. Complications with feeding, hygiene and PEG tube mobilization were denied by the caregivers. Polypnea and subcutaneous emphysema in the upper and lower left quadrants were noticed, as well as abdominal distension and diffuse tenderness with peritoneal signs. Abdominal plain radiography demonstrated pneumoperitoneum and the internal bumper of the PEG tube in intraperitoneal location (Fig. 1). An exploratory laparotomy was undertaken and a perforation site in the gastric