A 62-year-old male patient with underlying Type 2 diabetes mellitus
and hypertension underwent screening esophagogastroduodenoscopy. A 5-cm flat
nodular mucosal lesion, which was confirmed to be high grade dysplasia, was
noted at the upper body along the lesser curvature, just below the cardia ([Fig. 1]).
Fig. 1 A flat nodular mucosal
lesion at the upper body along the lesser curvature was diagnosed as high grade
dysplasia.
Endoscopic submucosal dissection (ESD) was performed at a universal
setting with high frequency apparatus (VIO300D; ERBE, Tübingen, Germany).
During the procedure, large amounts of bleeding occurred, which necessitated
frequent electrohemostasis, resulting in extensive tissue burn injury ([Fig. 2 a, b]).
Fig. 2 Extensive bleeding
during endoscopic submucosal dissection required frequent electrohemostasis.
a Electrohemostasis using hemostatic forceps with
80 W soft-mode coagulation. b Extensive tissue
burn injury due to excessive current application.
The total procedure time was 4 hours and 30 minutes. The following
day, fever of 38.5 ° C and abdominal pain developed.
Perforation was suspected, and abdominal computed tomography scan was
performed. Intramural gas was present from the plane of the fundal portion of
the stomach to the posterior wall of the mid-body, with accompanying edematous
wall thickening ([Fig. 3 a]).
Fig. 3 Conventional computed
tomography scan images. a Gas in the stomach wall from
the plane of the fundal portion to the posterior wall of the mid-body, with
edematous wall thickening. b Lung window setting
demonstrated even more intramural gas.
Intramural gas was even more evident in the lung window view ([Fig. 3 b]). The triad of fever, abdominal
pain, and air within the gastric wall led us to consider the possibility of a
potentially fatal emphysematous gastritis; thus, broad spectrum antibiotics
were promptly applied (ceftriaxone 2 g i. v. q. d.,
metronidazole 500 mg i. v. t. i. d.)
[1]
[2].
Fortunately, the fever and abdominal pain quickly subsided, just a
day after its initial manifestation. Due to the benign course of the
patient’s condition, we were able to make a diagnosis of gastric
emphysema (gastric pneumatosis) [3].
Well known complications of ESD are pain, bleeding, perforation, and
stricture [4]
[5]. To our knowledge,
this represents the first reported case of gastric emphysema as a complication
of ESD. We suggest the possible etiology to be the persistent intragastric
pressure elevation due to a prolonged procedure and excessive current
application for hemostasis. Due to its fast absorption, insufflation with
carbon dioxide may be considered in cases of prolonged ESD in order to prevent
emphysema.
Endoscopy_UCTN_Code_CPL_1AH_2AZ
