Tension pneumoperitoneum (TP) is defined as the massive accumulation of air in the peritoneal cavity, which results in a sudden increase in intraabdominal pressure. Various iatrogenic procedures are responsible for this complication (1). We report a case of tension pneumoperitoneum after percutaneous radiological gastrostomy (PRG).

Keywords: Percutaneous radiological gastrostomy, tension pneumoperitoneum, abdominal compartment syndrome.

1. Symeonidis N, Ballas K, Pavlidis E, Psarras K, Pavlidis T, Sakantamis A. Tension Pneumoperitoneum: A Rare Complication of Upper Gastrointestinal Endoscopy. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 2012;16 (3):495-497.
2. Shin JH, Park A-W. Updates on Percutaneous Radiologic Gastrostomy/ Gastrojejunostomy and Jejunostomy. Gut and Liver. 2010;4(Suppl 1): S25-S31. doi:10.5009/gnl.2010.4. S1. S25
3. Gauderer MW, Ponsky JL, Izant RJ., Jr Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980; 15:872–875.
4. Wiesen AJ, Sideridis K, Fernandes A, et al. True incidence and clinical significance of pneumoperitoneum after PEG place-ment: a prospective study. Gastrointest Endosc. 2006; 64:886–889.
5. Preshaw RM A percutaneous method for inserting a feeding gastrostomy tube. Surg Gynecol Obstet. 1981;152659- 660
6. Löser C, Aschlb G, Hebuternec X, et al. ESPEN guidelines on artificial enteral nutrition – Percutaneous endoscopic gastrostomy (PEG) ClinNutr. 2005; 24:848–61.
7. De Baere T, Chapot R, Kuoch V, et al. Percutaneous gastrostomy with fluoroscopic guidance: Single-centre experience in 500 consecutive cancer patients. Radiology. 1999; 210:651–4
8. Ozmen MN, Akhan O. Percutaneous radiologic gastrostomy. Eur J Radiol. 2002; 43:186–95.
9. Edelman DS, Unger SW. Laparoscopic gastrostomy. Surg. Gynecol. Obstet. 1991; 173: 401.
10. Edelman DS, Arroyo PJ, Unger SW. Laparoscopic gastrostomy versus percutaneous endoscopic gastrostomy: A comparison. SurgEndosc. 1994; 8:47–9.
11. Reck T, Köckerling F, Horbach T, Hohenberger W: Perkutanelapar-oskopische Gastrostomie (PLG). Zentralbl Chir 1997; 122:700–705.
12. Chan SY, Kirsch CM, Jensen WA, Sherck J. Tension pneumoperitoneum. West J Med 1996; 165: 61–64
13. Deenichin GP. Abdominal compartment syndrome. Surg Today. 2008; 38: 5–19
14. Conole FD, D'Angelo AA. Resection of pharyngeal diverticulum with spontaneous development of tension pneumoperi-toneum. Am J Surg 1952; 83:580-3.
15. Chiapponi C, Stocker U, Körner M, Ladurner R. Emergency percutaneous needle decompression for tension pneumoperitoneum. BMC Gastroenterol 2011; 11:48.
16. García-Santos E, Puerto-Puerto A, Sánchez-García S, Ruescas-García FJ. Alberca-Páramo A, Martín-Fernández J. [Abdominal compartment syndrome by tension pneumoperitoneum secondary to barotrauma. Presentation case]. Cir Cir. 2015 Sep-Oct;83(5):429-32.5
17. Burdett-Smith P, Jaffey L. Tension pneumoperitoneum. Journal of Accident & Emergency Medicine. 1996;13(3):220-221.
18. Lu TC, Chen SY, Wang HP, Lee CC. Tension pneumoperitoneum following upper gastrointestinal endoscopy. J Formos Med Assoc. 2006; 105: 431–433
19. Richmond BK, Mullins B, Jackson M, Dyer B, Agarwal S. Tension pneumoperitoneum resulting from endoscopic duodenal perforation: a case report. W V Med J. 2006 Nov-Dec;102(6):26-7.
20. Park WY, Lee TH, Lee JS, Hong SJ, Jeon SR, Kim HG, Cho JY, Kim JO, Cho JH, Lee SW, Cho YK. Reappraisal of Pneumoperitoneum After Percutaneous Endoscopic Gastrostomy. Intest Res. 2015 Oct;13(4):313-7.
21. Hillman KM. Pneumoperitoneum--a review. Crit Care Med. 1982 Jul;10(7): 476–481.
22. Hill HF, Bunting J, Wood RD, Temple JG. The significance of radiological pneumoperitoneum in the diagnosis of postoperative peritonitis. J R Coll Surg Edinb. 1978 Sep;23(5):303-4.
23. Nazarian A, Cross W, Kowdley GC. Pneumoperitoneum after percutaneous endoscopic gastrostomy among adults in the intensive care unit: incidence, predictive factors, and clinical significance. Am Surg. 2012 May;78 (5):591-4.
24. Roberts PA, Wrenn K, Lundquist S. Pneumoperitoneum after percutaneous endoscopic gastrostomy: a case report and review. J Emerg Med. 2005 Jan;28(1):45-8.
25. Dulabon GR, Abrams JE, Rutherford EJ. The incidence and significance of free air after percutaneous endoscopic gastros-tomy. Am Surg. 2002 Jun;68 (6):590-3. PubMed
26. Lee JY, Park KS. Pneumoperitoneum After Percutaneous Endoscopic Gastro-stomy: Does It Have Clinical Signifi-cance? Intestinal Research. 2015;13(4): 295-296. doi:10.5217/ir.2015.13.4.295.
27. Milanchi S, Allins A. Early pneumoperitoneum after percutaneous endoscopic gastrostomy in intensive care patients: sign of possible bowel injury. Am J Crit Care. 2007; 16:132–136.
28. Kealey WD, McCallion WA, Boston VE. Tension pneumoperitoneum: a potentially life-threatening complication of percuta-neous endoscopic gastrojejunostomy. J Pediatr Gastroenterol Nutr. 1996 Apr;22(3):334-5
29. Iscan Y, Karip B, Ozcabi Y, Ağca B, Alahdab Y, Memisoglu K. Pneumoperitoneum with subcutaneous emphysema after percutaneous endoscopic gastrostomy. Case Rep Surg. 2014; 2014:726878.
30. Bunni J, Bryson PJ, Higgs SM. Abdominal compartment syndrome caused by tension pneumoperitoneum in a scuba diver. Ann R Coll Surg Engl. 2012 Nov;94(8): e237-9
31. Wollman B, D'Agostino HB, Walus-Wigle JR, Easter DW, Beale A. Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology. 1995; 197:699–704.
32. Laasch HU, Martin DF. Radiologic gastrostomy. Endoscopy. 2007; 39:247–255
33. Funaki B, Zaleski GX, Lorenz J, Menocci PB, Funaki AN, Rosenblum JD, Straus C, Leef JA. Radiologic gastrostomy placement: pigtail- versus mushroom-retained catheters.
34. Han K, Kim MD, Kwon JH, Kim YS, Kim GM, Lee J, Choi W, Won JY, Lee DY. Randomized Controlled Trial Comparing Radiologic Pigtail-Retained Gastrostomy and Radiologic Mushroom-Retained Gastrostomy. J VascIntervRadiol. 2017 Dec;28(12):1702-1707.
35. Kasznia-Brown J, Cook C. Radiological signs of pneumoperitoneum: a pictorial review. Br J Hosp Med (Lond). 2006 Dec;67(12):634-9.
36. Marshall Geoffrey B. "The Cupola Sign." Radiology 241, no. 2 (November 1, 2006): 623-624.
37. Pinto A, Miele V, Schillirò ML, Nasuto M, Chiaese V, Romano L, Guglielmi G. Spectrum of Signs of Pneumoperitoneum. Semin Ultrasound CT MR. 2016 Feb;37(1):3-9.
38. Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr. 1992; 16:713–716.
39. Alun E. Jones, Dean Godfrey, Guy F. Nash. Tension pneumoperitoneum: innovative decompression of this general surgical emergency April 2011 Surgical Techniques Development v. 1, n. 2, p. e21, oct. 2011

Abbas AR Mohamed, MBBS, FRCSI, FICS, FACS

Consultant General and Laparoscopic Surgeon,

Department of Surgical Specialties, NGH –Madinah –KSA