Secondary Logo

Journal Logo

Spontaneous Pneumomediastinum, Pneumoperitoneum, and Pneumoretroperitoneum After Endoscopic Cryoablation Without Frank Perforation

Chen, Brendan MD1; Ferreira, Jason MD2

doi: 10.14309/crj.0000000000000204
CASE REPORT
Open

ABSTRACT Perforation after endoscopic cryoablation is a rare but serious complication. We present a middle-aged male patient who presented for an elective session of endoscopic cryoablation for his Barrett esophagus with high-grade dysplasia. After cryoablation, the patient complained of abdominal pain, and his abdomen became distended and tympanic. Computed tomography showed pneumomediastinum, pneumoperitoneum, and pneumoretroperitoneum but no evidence of extraluminal contrast extravasation. The patient was treated with antibiotics and had no complications. To our knowledge, this is the first described case of pneumomediastinum, pneumoperitoneum, and pneumoretroperitoneum without frank perforation after endoscopic cryoablation.

1Department of Medicine, Alpert Medical School of Brown University, Providence, RI

2Division of Gastroenterology, Alpert Medical School of Brown University, Providence, RI

Correspondence: Brendan Chen, MD, Rhode Island Hospital/Warren Alpert Medical School of Brown University, 593 Eddy St., Providence, RI 02903 (Brendan_chen@brown.edu).

Received January 30, 2019

Accepted July 23, 2019

Online date: August 14, 2019

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Back to Top | Article Outline

INTRODUCTION

Management of Barrett esophagus with high-grade dysplasia requires endoscopic eradication therapy. The most common modality is by radiofrequency ablation, although cryoablation has become popular as an alternative.1,2 Cryoablation involves freezing and subsequently destroying dysplastic cells using liquid nitrogen, carbon dioxide, or nitrous oxide. Currently, the most studied and most popular cryogen used is liquid nitrogen, which has shown good curative rates with few complications. Complications can range from pain and bleeding to strictures and rarely perforation.3–7 On imaging, esophageal perforation is often marked by abnormal air in surrounding structures such as the mediastinum or peritoneum.

Back to Top | Article Outline

CASE REPORT

A 54-year-old man with a history of Hepatitis C and compensated cirrhosis presented for an elective second session of endoscopic cryoablation for his Barrett esophagus with high-grade dysplasia. After undergoing 3 cryoablation cycles with liquid nitrogen, the patient's abdomen became distended and tympanic (Figure 1). He was noted to be taking shallow breaths. A 16-gauge Angiocath was inserted into his abdominal cavity above the umbilicus, and air was expressed from his peritoneal cavity indicative of a perforation. Repeat esophagogastroduodenoscopy was performed to try to find the area of perforation, so endoscopic treatment could be pursued. However, his repeat esophagogastroduodenoscopy was normal, and his duodenum, stomach, and esophagus insufflated well with no apparent leakage and no obvious mucosal defect was seen to indicate perforation (Figure 2). The Angiocath was removed, and his abdomen remained soft. When he was awakened from sedation, he was complaining of severe abdominal pain and in respiratory distress prompting repeat intubation. Computed tomography showed pneumomediastinum, pneumoperitoneum, and pneumoretroperitoneum with no evidence of extraluminal contrast extravasation (Figures 3–5). The patient was empirically started on piperacillin-tazobactam and fluconazole for perforation. The patient had a barium swallow, which was also negative for perforation. The patient did well and was extubated the following day and discharged 2 days later with a short course of amoxicillin-clavulanate.

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

Figure 4

Figure 4

Figure 5

Figure 5

Back to Top | Article Outline

DISCUSSION

Endoscopic cryoablation has been shown to be a safe therapy for Barrett esophagus with high-grade dysplasia.3–5 Perforations following cryoablation are rare and have only been reported 3 times in the literature (Table 1).7–9

Table 1

Table 1

To our knowledge, this is the first described case of pneumomediastinum, pneumoperitoneum, and pneumoretroperitoneum without frank perforation after endoscopic cryoablation. In our patient, it was likely secondary due to barotrauma on the gastrointestinal mucosa from the liquid nitrogen despite adequate ventilation through an orogastric tube to suction during the procedure. There has been one other case of pneumoperitoneum without frank perforation, but in that report, carbon dioxide was used, and the patient also had a percutaneous endoscopic gastrostomy tube, which may have weakened the peritoneum's ability to withstand barotrauma.9 In our patient, he did not have any known structural defects, and it is unlikely that his cirrhosis could have been a risk factor.

In our patient, prompt recognition of possible perforation and rapid decompression of the abdomen cryoablation may have been life-saving. For suspected perforation, we recommend using carbon dioxide insufflation and rapid Angiocath placement as we did in our case.

Back to Top | Article Outline

DISCLOSURES

Author contributions: All authors contributed equally to the manuscript. B. Chen is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

Back to Top | Article Outline

REFERENCES

1. Shaheen NJ, Falk GW, Iyer PG, Gerson LB; American College of Gastroenterology. ACG clinical guideline: Diagnosis and management of Barrett's esophagus. Am J Gastroenterol. 2016;111(1):30–50; quiz 51.
2. Rajaram R, Hofstetter WL. Mucosal ablation techniques for Barrett's esophagus and early esophageal cancer. Thorac Surg Clin. 2018;28(4):473–80.
3. Canto MI. Cryotherapy for Barrett's esophagus. Gastrointest Endosc Clin N Am. 2017;27(3):503–13.
4. Ramay FH, Cui Q, Greenwald BD. Outcomes after liquid nitrogen spray cryotherapy in Barrett's esophagus-associated high-grade dysplasia and intramucosal adenocarcinoma: 5-year follow-up. Gastrointest Endosc. 2017;86(4):626–32.
5. Ghorbani S, Tsai FC, Greenwald BD, et al. Safety and efficacy of endoscopic spray cryotherapy for Barrett's dysplasia: Results of the national cryospray registry. Dis Esophagus. 2016;29(3):241–7.
6. Gosain S, Mercer K, Twaddell WS, Uradomo L, Greenwald BD. Liquid nitrogen spray cryotherapy in Barrett's esophagus with high-grade dysplasia: Long-term results. Gastrointest Endosc. 2013;78(2):260–5.
7. Dumot JA, Vargo JJ II, Falk GW, Frey L, Lopez R, Rice TW. An open-label, prospective trial of cryospray ablation for Barrett's esophagus high-grade dysplasia and early esophageal cancer in high-risk patients. Gastrointest Endosc. 2009;70(4):635–44.
8. Canto MI, Shin EJ, Khashab MA, et al. Safety and efficacy of carbon dioxide cryotherapy for treatment of neoplastic Barrett's esophagus. Endoscopy. 2015;47(7):591.
9. Diehl DL, Jain AK, Greenwald BD. Pneumoperitoneum after esophageal cryoablation in a patient with a PEG. Surg Laparosc Endosc Percutan Tech. 2011;21(3):e141–2.
© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.