CONSERVATIVE MANAGEMENT OF RARE COMPLICATION OF GAS IN LESSER SAC AFTER EUS GUIDED CYSTOGASTROSTOMY

Aims:

Pneumoperitoneum after EUS guided cystogastrostomy is a rare complication presenting as shoulder pain. This is due to gas in lesser sac. This complication was managed conservatively with faster recovery.

Methods:

35 year old gentleman presented with persisting abdominal pain after developing pancreatitis a month earlier. CECT abdomen showed 10 × 12 cm pseudocyst in lesser sac. EUS guided cystogastrostomy was done. Two plastic stents were placed. Stents were close to GE junction. Post procedure patient complained of severe right shoulder pain only on upright posture. Physical examination showed a soft but tympanic abdomen. X ray showed pneumoperitoneum, more on right side. CT scan revealed gas in lesser sac, with remnant fluid collection and stents in situ. Patient was treated with oxygen supplementation and kept nil per oral for 48 hours, after which shoulder pain significantly reduced. His appetite was normal. He tolerated normal diet well after 48 hours. He was observed for 3 more days in hospital. Repeat X ray showed mild reduction of gas shadow. Tympanic note reduced after 5 days.

Results:

Pneumoperitoneum after EUS guided cystogastrostomy is a rare complication for which surgical intervention was the usual management. However, pneumoperitoneum in this patient is due to gas in lesser sac. As the only symptom is short lasting shoulder pain in the setting of normal enteral motility and absence of peritonitis, conservative management with early enteral feeding has proven effective. Gas in lesser sac may take time to resolve, and need not be a criteria for surgical intervention

Conclusions:

We report a rare case of lesser sac gas after EUS guided cystogastrotomy, which was symptomatic for short duration and managed conservatively followed by early enteral nutrition