Gastric Perforation, a Rare Consequence of Unintentional Esophageal Intubation
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Abstract
Accidental esophageal intubation is a preventable human error that complicates airway management and continues to occur despite advances in medical devices. Perforation of the stomach has been associated with esophageal intubation in several case reports.This report presents a case of an elderly woman suspected of having COVID-19-related pneumonia. She was intubated due to respiratory dysfunction. In the initial few minutes, the patient became desaturated, leading to a second intubation. An hour later, the patient’s abdomen was distended, and the chest computed tomography (CT) showed a massive pneumoperitoneum. During laparotomy, a 6 cm long rupture was found in the lesser curvature, which was attributed to accidental esophageal intubation. To avoid such a fatal condition, it is imperative for physicians to ensure the correct positioning of the endotracheal tube. To achieve this goal, further investigation into readily available and highl y sensitive techniques is recommended.
[1]Hahn CD, Choi YU, Lee D, Frizzi JD. Pneumoperitoneum due to gastric perforation after cardiopulmonary resuscitation:
case report. Am J Crit Care. 2008;17(4):388, 6-7. https://doi. org/10.4037/ajcc2008.17.4.388
[2]Sigmon DF, Tuma F, Kamel BG, Cassaro S. Gastric Perforation. StatPearls. Treasure Island (FL) ineligible companies. Disclosure: Faiz Tuma declares no relevant financial relationships with
ineligible companies. Disclosure: Bishoy Kamel declares no relevant financial relationships with ineligible companies. Disclosure: Sebastiano Cassaro declares no relevant financial relationships with ineligible companies. Treasure Island (FL): StatPearls Publishing LLC.; 2023.
[3]Kang DH, Ryu DG, Choi CW, Kim HW, Park SB, Kim SJ, et al. Clinical outcomes of iatrogenic upper gastrointestinal
endoscopic perforation: a 10-year study. BMC Gastroenterol. 2019;19(1):218. https://doi.org/10.1186/s12876-019-1139-1
[4] Wolff AT, Hohenstein C. Gastric perforation after mouth-to-mouth ventilation: a case report. Eur J Anaesthesiol. 2015;32(2):138-9. https://doi.org/10.1097/ EJA.0000000000000143
[5] Bednarz S, Filipovic M, Schoch O, Mauermann E. Gastric rupture after bag-mask-ventilation. Respir Med Case Rep. 2015;16:1-2. https://doi.org/10.1016/j.rmcr.2015.05.014
[6]Spoormans I, Van Hoorenbeeck K, Balliu L, Jorens PG. Gastric perforation after cardiopulmonary resuscitation: review of the literature. Resuscitation. 2010;81(3):272-80. https://doi. org/10.1016/j.resuscitation.2009.11.023
[7]Nishimura T, Shirai K, Nakao A, Kotani J. Gastric Perforation Because of Non-Invasive Positive-Pressure Ventilation: Review of Complications. Surg Infect Case Rep. 2016;1:41-3. https:// doi.org/10.1089/crsi.2016.29008.tn
[8]Suwanwongse K, Shabarek N. Gastric Perforation: A Rare Accident from Intubation. Cureus. 2020;12(1):e6684. https:// doi.org/10.7759/cureus.6684
[9]Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. 2001;37(1):32-7. https://doi.org/10.1067/mem.2001.112098
[10] Jones JH, Murphy MP, Dickson RL, Somerville GG, Brizendine EJ. Emergency physician-verified out-of-hospital intubation: miss rates by paramedics. Acad Emerg Med. 2004;11(6):707-9. https://doi.org/10.1111/j.1553-2712.2004.tb00730.x
[11] Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by
ground prehospital providers. Prehosp Emerg Care. 2007;11(2):213-8. https://doi.
org/10.1080/10903120701205935
[12]Schvadron E, Moses Y, Weissberg D. Gastric rupture complicating inadvertent intubation of the esophagus. Can J Surg. 1996;39(6):487-9.
[13] Song JK, Stern EJ, Beaty CD. Gastric perforation: a complication of inadvertent esophageal intubation. 1995;164(6):1386-. https://doi.org/10.2214/ajr.164.6.7754878
[14] Hershey MD, Hannenberg AA. Gastric Distention and Rupture from Oxygen Insufflation during Fiberoptic Intubation. Anesthesiology. 1996;85(6):1479-80. https://doi. org/10.1097/00000542-199612000-00030
[15] Gilbert TB. Gastric Rupture after Inadvertent Esophageal Intubation with a Jet Ventilation Catheter Anesthesiology. 1998;88(2):537-8. https://doi.org/10.1097/00000542-199802 000-00037
[16] Chen PN, Shih CK, Li YH, Cheng WC, Hsu HT, Cheng KI. Gastric perforation after accidental esophageal intubation in a patient with deep neck infection. Acta Anaesthesiol Taiwan. 2014;52(3):143-5. https://doi.org/10.1016/j.aat.2014.06.001
[17] Marcucci V, Bhattacharyya R, Yee S, Zuberi J, Ingram M. Gastric Perforation with Omental Patch Repair: A Rare Complication of Pulmonary Resuscitation in COVID-19 Pneumonia. Case Rep Surg. 2020;2020:8850739. https://doi.org/10.1155/2020/8850739
[18] Akıncı O, Akıncı Ö. Gastric perforation: An unusual complication after esophageal intubation. Ulus Travma Acil Cerrahi Derg. 2022;28(7):1035-7. https://doi.org/10.14744/tjtes.2022.08395
[19] Lelcuk S, Leibovitch I, Kaplan O, Rozin RR. Stomach rupture caused by false intubation of the esophagus. Isr J Med Sci. 1990;26(3):167-8.
[20] Kim HC, Yang DM, Kim SW, Park SJ. Gastrointestinal tract perforation: evaluation of MDCT according to perforation site and elapsed time. Eur Radiol. 2014;24(6):1386-93. https://doi. org/10.1007/s00330-014-3115-z
[21] Tang SJ, Daram SR, Wu R, Bhaijee F. Pathogenesis, diagnosis, and management of gastric ischemia. Clin Gastroenterol Hepatol. 2014;12(2):246-52.e1. https://doi.org/10.1016/j.cgh.2013.07.025
[22] Smally AJ, Ross MJ, Huot CP. Gastric rupture following bag- valve-mask ventilation. J Emerg Med. 2002;22(1):27-9. https://doi.org/10.1016/S0736-4679(01)00433-4
[23] Jiang J, Ma D, Li B, Yue Y, Xue F. Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2017;21(1):288. https://doi.org/10.1186/s13054-017-1885-9
[24] Baker PA, O’Sullivan EP, Aziz MF. Unrecognised oesophageal intubation: time for action. Br J Anaesth. 2022;129(6):836-40. https://doi.org/10.1016/j.bja.2022.08.027
[25] Honardar MR, Posner KL, Domino KB. Delayed Detection of Esophageal Intubation in Anesthesia Malpractice Claims: Brief Report of a Case Series. Anesth Analg. 2017;125(6):1948-51. https://doi.org/10.1213/ANE.0000000000001795
case report. Am J Crit Care. 2008;17(4):388, 6-7. https://doi. org/10.4037/ajcc2008.17.4.388
[2]Sigmon DF, Tuma F, Kamel BG, Cassaro S. Gastric Perforation. StatPearls. Treasure Island (FL) ineligible companies. Disclosure: Faiz Tuma declares no relevant financial relationships with
ineligible companies. Disclosure: Bishoy Kamel declares no relevant financial relationships with ineligible companies. Disclosure: Sebastiano Cassaro declares no relevant financial relationships with ineligible companies. Treasure Island (FL): StatPearls Publishing LLC.; 2023.
[3]Kang DH, Ryu DG, Choi CW, Kim HW, Park SB, Kim SJ, et al. Clinical outcomes of iatrogenic upper gastrointestinal
endoscopic perforation: a 10-year study. BMC Gastroenterol. 2019;19(1):218. https://doi.org/10.1186/s12876-019-1139-1
[4] Wolff AT, Hohenstein C. Gastric perforation after mouth-to-mouth ventilation: a case report. Eur J Anaesthesiol. 2015;32(2):138-9. https://doi.org/10.1097/ EJA.0000000000000143
[5] Bednarz S, Filipovic M, Schoch O, Mauermann E. Gastric rupture after bag-mask-ventilation. Respir Med Case Rep. 2015;16:1-2. https://doi.org/10.1016/j.rmcr.2015.05.014
[6]Spoormans I, Van Hoorenbeeck K, Balliu L, Jorens PG. Gastric perforation after cardiopulmonary resuscitation: review of the literature. Resuscitation. 2010;81(3):272-80. https://doi. org/10.1016/j.resuscitation.2009.11.023
[7]Nishimura T, Shirai K, Nakao A, Kotani J. Gastric Perforation Because of Non-Invasive Positive-Pressure Ventilation: Review of Complications. Surg Infect Case Rep. 2016;1:41-3. https:// doi.org/10.1089/crsi.2016.29008.tn
[8]Suwanwongse K, Shabarek N. Gastric Perforation: A Rare Accident from Intubation. Cureus. 2020;12(1):e6684. https:// doi.org/10.7759/cureus.6684
[9]Katz SH, Falk JL. Misplaced endotracheal tubes by paramedics in an urban emergency medical services system. Ann Emerg Med. 2001;37(1):32-7. https://doi.org/10.1067/mem.2001.112098
[10] Jones JH, Murphy MP, Dickson RL, Somerville GG, Brizendine EJ. Emergency physician-verified out-of-hospital intubation: miss rates by paramedics. Acad Emerg Med. 2004;11(6):707-9. https://doi.org/10.1111/j.1553-2712.2004.tb00730.x
[11] Wirtz DD, Ortiz C, Newman DH, Zhitomirsky I. Unrecognized misplacement of endotracheal tubes by
ground prehospital providers. Prehosp Emerg Care. 2007;11(2):213-8. https://doi.
org/10.1080/10903120701205935
[12]Schvadron E, Moses Y, Weissberg D. Gastric rupture complicating inadvertent intubation of the esophagus. Can J Surg. 1996;39(6):487-9.
[13] Song JK, Stern EJ, Beaty CD. Gastric perforation: a complication of inadvertent esophageal intubation. 1995;164(6):1386-. https://doi.org/10.2214/ajr.164.6.7754878
[14] Hershey MD, Hannenberg AA. Gastric Distention and Rupture from Oxygen Insufflation during Fiberoptic Intubation. Anesthesiology. 1996;85(6):1479-80. https://doi. org/10.1097/00000542-199612000-00030
[15] Gilbert TB. Gastric Rupture after Inadvertent Esophageal Intubation with a Jet Ventilation Catheter Anesthesiology. 1998;88(2):537-8. https://doi.org/10.1097/00000542-199802 000-00037
[16] Chen PN, Shih CK, Li YH, Cheng WC, Hsu HT, Cheng KI. Gastric perforation after accidental esophageal intubation in a patient with deep neck infection. Acta Anaesthesiol Taiwan. 2014;52(3):143-5. https://doi.org/10.1016/j.aat.2014.06.001
[17] Marcucci V, Bhattacharyya R, Yee S, Zuberi J, Ingram M. Gastric Perforation with Omental Patch Repair: A Rare Complication of Pulmonary Resuscitation in COVID-19 Pneumonia. Case Rep Surg. 2020;2020:8850739. https://doi.org/10.1155/2020/8850739
[18] Akıncı O, Akıncı Ö. Gastric perforation: An unusual complication after esophageal intubation. Ulus Travma Acil Cerrahi Derg. 2022;28(7):1035-7. https://doi.org/10.14744/tjtes.2022.08395
[19] Lelcuk S, Leibovitch I, Kaplan O, Rozin RR. Stomach rupture caused by false intubation of the esophagus. Isr J Med Sci. 1990;26(3):167-8.
[20] Kim HC, Yang DM, Kim SW, Park SJ. Gastrointestinal tract perforation: evaluation of MDCT according to perforation site and elapsed time. Eur Radiol. 2014;24(6):1386-93. https://doi. org/10.1007/s00330-014-3115-z
[21] Tang SJ, Daram SR, Wu R, Bhaijee F. Pathogenesis, diagnosis, and management of gastric ischemia. Clin Gastroenterol Hepatol. 2014;12(2):246-52.e1. https://doi.org/10.1016/j.cgh.2013.07.025
[22] Smally AJ, Ross MJ, Huot CP. Gastric rupture following bag- valve-mask ventilation. J Emerg Med. 2002;22(1):27-9. https://doi.org/10.1016/S0736-4679(01)00433-4
[23] Jiang J, Ma D, Li B, Yue Y, Xue F. Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2017;21(1):288. https://doi.org/10.1186/s13054-017-1885-9
[24] Baker PA, O’Sullivan EP, Aziz MF. Unrecognised oesophageal intubation: time for action. Br J Anaesth. 2022;129(6):836-40. https://doi.org/10.1016/j.bja.2022.08.027
[25] Honardar MR, Posner KL, Domino KB. Delayed Detection of Esophageal Intubation in Anesthesia Malpractice Claims: Brief Report of a Case Series. Anesth Analg. 2017;125(6):1948-51. https://doi.org/10.1213/ANE.0000000000001795
| Files | ||
| Issue | Vol 8 No 4 (2023): July-August | |
| Section | Case Report(s) | |
| DOI | https://doi.org/10.18502/crcp.v8i4.14579 | |
| Keywords | ||
| Intubation Complication Esophageal intubation Gastric perforation | ||
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How to Cite
1.
Faghih Soleimani MFS, Yamini A, Amiri E, Khosronezhad S. Gastric Perforation, a Rare Consequence of Unintentional Esophageal Intubation. CRCP. 2024;8(4):171-175.
