ONLINE CASE REPORT Ann R Coll Surg Engl 2012; 94: e210–e212 doi 10.1308/003588412X13171221502347 Gastric perforation in an adult male following nasogastric intubation P Daliya, TJ White, KR Makhdoomi Sherwood Forest Hospitals NHS Foundation Trust, UK ABSTRACT IntroductIon Spontaneous gastric perforation is a well known surgical emergency which carries significant mortality and morbidity. Well documented causes in adults include peptic ulcer disease, drugs such as non-steroidal and gastric malignancy. Iatrogenic causes still remain relatively rare. We report an interesting case of an acutely unwell young man who developed gastric perforation secondary to nasogastric intubation. caSe report a 32 year old man initially treated for gastroenteritis underwent laparotomy for acute intra-abdominal bleed- ing. this was found to be secondary to a ruptured left hepatic artery aneurysm which was subsequently embolised. patient had multiple laparotomies, a nasogastric tube inserted at the second laparotomy was later found to be the cause of gastric perfora- tion. on further investigation the patient’s multiple aneurysms were histologically confirmed to be secondary to fibromuscular dysplasia (FMd). concluSIon We present here a case of gastric perforation from a nasogastric tube in an adult male and discussed its rel- evance to the diagnosis of FMd. this case highlights the importance of having a high index of suspicion for this complication when managing patients with severe abdominal sepsis. KEywORdS Gastric perforation – Nasogastric intubation – Fibromuscular dysplasia accepted 13 october 2011; published online 26 September 2012 CORRESPONdENCE TO Khalid R Makhdoomi, consultant Vascular Surgeon, department of General Surgery, King’s Mill Hospital, Mansfield road, Sutton in ashfield, nottinghamshire nG17 4Jl, uK t: +44 (0)1623 622 515; e: [email protected] Spontaneous gastric perforation can be life threatening and bleeding. carries significant morbidity and mortality. The mostcom- An emergency laparotomy revealed free blood in the mon cause is peptic ulcer disease secondary to pharma- abdomen and a ruptured aneurysm of the left hepatic cological agents such as non-steroidal anti-inflammatory artery. As it was not possible to control the bleeding by drugs (NSAIDs) or steroids and, less commonly, neoplasia.1 ligation, the abdomen was packed and the patient taken Iatrogenic causes such as nasogastric (NG) and orogastric to the angiography suite, where the left hepatic artery was tube placement are extremely rare despite their frequent embolised. In addition to the left hepatic artery aneurysm, use in surgical and critically ill patients.1,2 We present the angiography also revealed splenic and renal artery aneu- case of a previously fit and well adult male patient who de- rysms. veloped gastric perforation following NG intubation. A relaparotomy was performed 48 hours later to remove the abdominal pack and ligate the large splenic artery an- eurysm. An NG tube was inserted during this operation, Case history which also found the left lobe of the liver to be ischaemic A 32-year-old man was admitted under the medical but no gastric or intestinal compromise. One week later, the team with a 2-day history of diarrhoea, vomiting and gen- patient became acutely unwell, developed peritonitis and eralised abdominal pain. On admission his haemoglobin started to deteriorate. Abdominal computed tomography was 12.9g/dl and urea 10.3mmol/l. A working diagnosis of was arranged to visualise the liver necrosis after the em- gastroenteritis was made and he was rehydrated with in- bolisation and revealed the radiolucent tip of the NG tube travenous fluids. Within hours of admission he became outside the stomach wall (Figs 1 and 2) with extravasation acutely unwell with increasing abdominal pain, distension of the oral contrast (Fig 2). The NG tube was pulled back and signs of shock. His haemoglobin was now 6.3g/dl and and an erect chest x-ray demonstrated new free air under clinical examination demonstrated signs of intra-abdominal the diaphragms (Fig 3). An emergency relaparotomy con- e210 Ann R Coll Surg Engl 2012; 94: e210–e212 dalIya WHIte MaKHdooMI GASTRIC PERfORATION IN AN AduLT MALE fOLLOwING NASOGASTRIC INTuBATION figure 1 nasogastric tube tip seen outside the stomach lumen instead of nasogastric tube tip seen out with the stomach figure 3 erect chest x-ray confirming perforation following withdrawal of the nasogastric tube Table 1 fibromuscular dysplasia (fMd) classification fMd type description I affects 80% of cases consisting of a series of ste- nosis alternating with areas of dilatation. Histology shows medial fibroplasias. II affects 15% of cases demonstrating unifocal with multifocal tubular stenosis. Histology shows intimal fibroplasias. III affects 5% of cases involving a single wall of the artery but with resultant thinning that can cause true saccular aneurysm formation due to atypical FMd. least three of these patients had clearly documented risk factors, which could explain why perforation occurred so readily following NG tube placement (salicylate use, gastric figure 2 extravasation of oral contrast from site of gastric anastomosis and metastatic gastro-oesophageal cancer). perforation In our case report, this previously well patient had no prior history of peptic ulcer disease or use of NSAIDs. We do not know for certain why an NG tube caused perfora- firmed gastric perforation, which was repaired by an omen- tion in our patient as the stomach is thick-walled and well tal patch. perfused in adults. Combined with the fact that the gastric Since discharge, histopathological analysis has con- blood supply was never compromised during embolisation, firmed the diagnosis of fibromuscular dysplasia (FMD) as this renders the possibility of gastric ischaemia unlikely but the cause for this patient’s multiple aneurysms. not impossible. A case reported by Lee et al2 and one by Ghahremani et al1 describe the occurrence of spontaneous gastric perfora- discussion tion following NG intubation. The action of gastrointestinal Oesophageal and pharyngo-oesophageal perforation are juices on the plastic NG tubing can cause previously flexible known complications of NG intubation in adults, unlike gas- NG tubes to become rigid and potentially cause pressure is- tric perforation, which is more common in infants.3 A case chaemia.2,4 Similar presentations have been described fol- series reported by Ghahremani et al in 1980 described six lowing NG intubation by a transoesophageal echocardiog- cases of gastric perforation following NG intubation.1 At raphy probe5 and Linton tube.1 Ann R Coll Surg Engl 2012; 94: e210–e212 e211 dalIya WHIte MaKHdooMI GASTRIC PERfORATION IN AN AduLT MALE fOLLOwING NASOGASTRIC INTuBATION Conclusions The only significant finding in our case was that of the diagnosis of FMD. FMD is a non-atherosclerotic, We present an interesting case of gastric perforation in an non-inflammatory arterial disease of unknown aetiology.6,7 adult caused by NG intubation on a background of FMD. It typically presents in the third to sixth decades with a Although extremely rare, one needs to be aware of this 3:1 female-to-male preponderance. Muscular hyperplasia complication, particularly in patients with severe abdomi- and fibrosis cause thickening of the arterial media with nal sepsis. multifocal arterial stenosis. The renal artery is the most commonly affected, with the internal carotid artery being References the next most common.8,9 Both of these were aneurysmal 1. Ghahremani GG, turner Ma, port rB. Iatrogenic intubation injuries of the upper in our patient. gastrointestinal tract in adults. Gastrointest Radiol 1980; 5: 1–10. 2. lee SH, Kim MS, Kim KH et al. Gastric perforation caused by nasogastric Radiologically, FMD is classified into three types (Table intubation in a patient on peritoneal dialysis. Korean J Nephrol 2007; 26: 1).10 According to this classification, our patient had the rare 250–253. type III FMD, presenting as a ruptured left hepatic artery 3. Gharehbaghy MM, rafeey M. acute gastric perforation in neonatal period. Med aneurysm. J Islamic Acad Sci 2001; 14: 67–69. 4. Ghahremani GG, Gould rJ. nasogastric feeding tubes. radiographic detection The aetiology of FMD is unknown although pathological of complications. Dig Dis Sci 1965; 31: 574–585. studies demonstrate the involvement of the smooth muscle 5. Soong W, afifi S, McGee ec. delayed presentation of gastric perforation after cells of the arterial media. Changes in the smooth muscle transesophageal echocardiography for cardiac surgery. Anesthesiology 2006; ultrastructure lead to fibrosis, post-stricture dilatation and 105: 1,273–1,274. subsequent saccular aneurysm formation.9 Little is known 6. rodriguez urrego pa, Flanagan M, tsai WS et al. Massive gastrointestinal bleeding: an unusual case of asymptomatic extrarenal, visceral, fibromuscular about the possible relations between FMD and other smooth dysplasia. World J Gastroenterol 2007; 13: 5,771–5,774. muscle organs in the body. Visceral FMD has been report- 7. la Batide alanore a, perdu J, ploufin pF. Fibromuscular dysplasia. Presse Med ed in the gut, causing cases of mesenteric ischaemia6 and 2007; 36: 1,016–1,023. proctitis.11 However, there are no reports on its effect on the 8. Berceli Sa. Hepatic and splenic artery aneurysms. Semin Vasc Surg 2005; 18: 196–201. stomach. 9. Stanley Jc, Wakefield tW. arterial Fibrodysplasia. In: rutherford rB, ed. In 2001 Vuong et al described a case of gastric ischae- Vascular Surgery. 5th ed. philadelphia, pa: Saunders; 2000. pp387–408. mia secondary to fibrodysplasia in von Recklinghausen’s 10. Fligelstone l. chapter 9: Fibromuscular dysplasia. In: parvin Sd, earnshaw JJ, disease12 while in 2003 Dinan et al reported a case of gas- eds. Rare Vascular Disorders. telford: tFM; 2005. pp53–57. tric wall weakening and perforation secondary to Duchenne 11. Quirke p, campbell I, talbot Ic. Ischaemic proctitis and adventitial fibromuscular dysplasia of the superior rectal artery. Br J Surg 1984; 71: muscular dystrophy.13 As we know, the stomach also con- 33–38. sists of smooth muscle and it is a possibility that this could 12. Vuong pn, le Bourgeois p, Houissa-Vuong S et al. Intimal muscular also be involved in the pathogenesis of FMD. Unfortunately, fibrodysplasia responsible for an ischemic gastric ulcer in a patient with a von this can only be confirmed for certain by tissue sampling, recklinghausen’s disease: a case report. J Mal Vasc 2001; 26: 65–68. 13. dinan d, levine MS, Gordon ar et al. Gastric wall weakening resulting in which was not performed intra-operatively. separate perforations in a patient with duchenne’s muscular dystrophy. Am J Roentgenol 2003; 181: 807–808. e212 Ann R Coll Surg Engl 2012; 94: e210–e212