AJR 2001; 177:693-694
© American Roentgen Ray Society
Subcutaneous Emphysema in a Pediatric Patient After Radiologic Placement of a Percutaneous Gastrostomy Tube
Stacey Bernstein1,
Michael Weinstein1,
Bairbre Connolly2 and
Michael Temple2
1
Department of Paediatrics, University of Toronto, The Hospital for Sick
Children, 555 University Ave., Toronto, Ontario M5G 1X8, Canada.
2
Department of Medical Imaging, University of Toronto, The Hospital for Sick
Children, Toronto, Ontario M5G 1X8, Canada.
Received January 12, 2001;
accepted after revision March 9, 2001.
Address correspondence to S. Bernstein.
Introduction
Gastrostomy tubes that are placed radiologically are associated with low
morbidity and low mortality and have a high success rate in infants, children,
and adults [1,
2]. Major complications
reported include death, sepsis, peritonitis, and hemorrhage, as well as tube
leakage, extrusion, and misplacement. We report the case of a male infant who
developed progressive, extensive pneumoperitoneum and subcutaneous emphysema
after gastrostomy tube insertion. This complication has been reported in
adults [3], and there is no
reason to believe that it could not occur in infants and children. To our
knowledge, this is the first reported case in the pediatric population.
Case Report
A 7-month-old male infant with oral motor feeding problems caused by
kernicterus related to glucose-6-phosphate dehydrogenase deficiency underwent
imaging-guided retrograde percutaneous gastrostomy tube placement. An IV
antibiotic (cefazolin) was administered before the procedure in accordance
with routine practice, and a 10-French pigtail catheter (Cook, Bloomington,
IN) was placed using techniques previously described in the literature
[1]. One retention suture (Cope
pediatric gastrointestinal suture; Cook) was introduced into the stomach, and
its external end was taped around a gauze roll. The gastrostomy tube was
secured with an adhesive dressing.
Twelve hours after the procedure and before feeding commenced, the infant
developed a temperature of 40°C associated with a tender abdomen and
increased leakage of "coffee-ground" material through and around
the gastrostomy tube. Fluoroscopy with contrast medium injection confirmed
that the tube was correctly positioned, with no leakage around the catheter,
but showed a moderate pneumoperitoneum. Broadspectrum antibiotics (ampicillin,
gentamycin, and metronidazole) and H2 blockers (ranitidine) were
administered, and a nasogastric tube was placed for intermittent suction.
Thirty-six hours after gastrostomy tube placement, substantial subcutaneous
emphysema extending around the flanks and into the chest wall was noted
(Fig. 1A). Because the
subcutaneous emphysema was accompanied by persistent high fever and
progressive pneumoperitoneum, the infant underwent fascial exploration of the
left flank to rule out necrotizing fasciitis. There was no separation of the
fascial planes, the gram stain from the area was negative, and the cultures
were sterile. A CT scan again confirmed the correct position of the
gastrostomy tube in the stomach and the presence of subcutaneous emphysema
(Fig. 1B). Despite this,
contrast medium injected through the tube filled the subcutaneous tissues. Our
presumption was that the tube was intermittently migrating back and forth in
the tract. We attempted to advance the tube and tape it firmly in place.
Nevertheless, the pneumoperitoneum and subcutaneous emphysema persisted, and
the tube was removed 4 days later.
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Fig. 1A. —7-month-old male infant with extensive subcutaneous emphysema
after radiologic placement of percutaneous gastrostomy tube. Chest radiograph
reveals subcutaneous air (small arrow) between muscle layers
(arrowhead) and skin (large arrow), with subcutaneous air
bubbles (asterisk). Infant pulled out nasogastric tube; note pigtail
gastrostomy in situ with contrast material in stomach and residual colonic
barium in hepatic and splenic flexures.
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Fig. 1B. —7-month-old male infant with extensive subcutaneous emphysema
after radiologic placement of percutaneous gastrostomy tube. CT scan reveals
subcutaneous air bubbles (white asterisk) between skin (large
arrow) and muscle layers (black asterisk) that surround abdomen.
Gastrostomy tube tip is visible in air-filled body of stomach (open
arrow). Note small bubble of free air at edge of liver
(arrowhead) and inflammatory changes in left anterior abdominal wall
(small arrows).
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The infant recovered after a 10-day course of antibiotic therapy and total
parenteral nutrition.
Discussion
The few reported cases of subcutaneous emphysema occurring after
gastrostomy tube placement have involved adults
[3,4,5,6].
Most cases occurred 4-7 days after placement of the percutaneous endoscopic
gastrostomy tube. A variety of explanations for this unusual complication have
been proposed.
Subcutaneous emphysema has been attributed to mechanical events at the time
of tube insertion. In one case, a 66-year-old man developed subcutaneous
emphysema with moderate pneumoperitoneum 4 days after receiving a
radiologically placed tube [3].
Although a contrast-enhanced study revealed that the tube was in the proper
position, leakage of gastric acid was noted at the insertion site 3 days
later, and it was discovered that the tube had retracted into the subcutaneous
tissues. The authors suggested that the tube was intermittently migrating
because the external fixation device had been removed; they hypothesized that
the pressure gradient between the bowel lumen (60 cm H2O) and the
soft tissue (5 cm H2O) drove the gas into the subcutaneous tissue
when a nonepithelialized tract was present. Others
[4] have recommended leaving a
patulous skin opening at the time of insertion to allow the escape of gas.
Another study [5] recommended
not apposing the stomach too tightly to the abdominal wall because doing so
might lead to pressure necrosis, causing the tracking of gas into the
subcutaneous region. Perforation of a bowel loop at the time of insertion
could also lead to pneumoperitoneum and subsequent subcutaneous emphysema.
Infection needs to be excluded as a cause in patients with subcutaneous
emphysema, especially when it is accompanied by signs of toxicity such as
fever, leukocytosis, purulent drainage at the gastrostomy site, or
peritonitis. Infections with gas-producing organisms, necrotizing fasciitis,
and subcutaneous abscess formation have all been reported after gastrostomy
tube placement
[4,5,6].
Specific host-related factors have also contributed to the development of
subcutaneous emphysema. In one case, a woman with amyotrophic lateral
sclerosis had a respiratory arrest after placement of a gastrostomy tube
[7]. There was difficulty
managing her airway, and she underwent an esophageal intubation. As a result
of forced air into a freshly placed tube, with ventilation of the gastric
lumen, she developed subcutaneous emphysema. Another patient developed gastric
overdistention after being placed on a respirator
[8].
This report describes the first case, to our knowledge, of subcutaneous
emphysema in a pediatric patient after radiologic placement of a gastrostomy
tube. Subcutaneous emphysema has been previously described in adults, and it
is therefore reasonable to infer that it could occur in children. This is the
first such case recognized at The Hospital for Sick Children, despite
placement of more than 1500 tubes by interventional radiologists (Connolly B,
personal communication). Various factors may have played a role in the
development of subcutaneous emphysema in our patient. The infant was
developmentally delayed, had seizures and hypertonia, and vomited as a result
of reflux, all of which placed him at risk for tube migration. Perhaps, if the
tube had been marked or externally fixed, we could have detected migration
more easily.
Our patient's tube was initially seen to be in the correct position on
fluoroscopy and CT, but immediate subsequent fluoroscopy showed leakage of
contrast medium into the subcutaneous tissues. This is consistent with the
intermittent movement of the tube in and out of the tract. Alternatively,
tension on the retention suture and the gastric coil, in an attempt to keep
the tract short, may have resulted in too much pressure on the tissue. Our
patient was extremely irritable and cried a lot, causing gastric distention
due to aerophagia. More aggressive nasogastric suction and pain control might
have reduced the size of the developing pneumoperitoneum.
Feeding gastrostomy is a well-accepted means of providing enteral nutrition
to patients unable to meet their caloric needs orally. As a result of
gastrostomy placement, our patient had a prolonged hospital stay, an
exploratory fasciotomy, numerous investigative procedures, and, in the end,
was left without a tube.
This case serves as a reminder that readily available, minimally invasive
radiologically placed tubes are not without complications.
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Introduction
Case Report
