Dai ZC, Gui XW, Yang FH, Zhang HY, Zhang WF. Perforated gastric ulcer causing mediastinal emphysema: A case report. World J Clin Cases 2024; 12(4): 859-864 [PMID: 38322697 DOI: 10.12998/wjcc.v12.i4.859]
Corresponding Author of This Article
Wen-Feng Zhang, MD, Chief Physician, Department of General Surgery, Mengcheng County First People's Hospital, No. 282 Shangcheng East Road, Mengcheng 233500, Anhui Province, China. zwf197801@163.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Zhi-Cheng Dai, Xun-Wu Gui, Feng-He Yang, Wen-Feng Zhang, Department of General Surgery, Mengcheng County First People's Hospital, Mengcheng 233500, Anhui Province, China
Hao-Yuan Zhang, Department of Medical Imaging, Mengcheng County First People's Hospital, Mengcheng 233500, Anhui Province, China
Author contributions: Dai ZC, Yang FH, and Gui XW compiled the literature and data; Dai ZC and Zhang HY drafted the paper and prepared the figures; Dai ZC and Zhang WF reviewed and revised the final version of the paper.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: All the authors declare that they have no conflict of interest to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Wen-Feng Zhang, MD, Chief Physician, Department of General Surgery, Mengcheng County First People's Hospital, No. 282 Shangcheng East Road, Mengcheng 233500, Anhui Province, China. zwf197801@163.com
Received: December 3, 2023 Peer-review started: December 3, 2023 First decision: December 12, 2023 Revised: December 14, 2023 Accepted: January 8, 2024 Article in press: January 8, 2024 Published online: February 6, 2024 Processing time: 52 Days and 21.6 Hours
Abstract
BACKGROUND
Mediastinal emphysema is a condition in which air enters the mediastinum between the connective tissue spaces within the pleura for a variety of reasons. It can be spontaneous or secondary to chest trauma, esophageal perforation, medically induced factors, etc. Its common symptoms are chest pain, tightness in the chest, and respiratory distress. Most mediastinal emphysema patients have mild symptoms, but severe mediastinal emphysema can cause respiratory and circulatory failure, resulting in serious consequences.
CASE SUMMARY
A 75-year-old man, living alone, presented with sudden onset of severe epigastric pain with chest tightness after drinking alcohol. Due to the remoteness of his residence and lack of neighbors, the patient was found by his nephew and brought to the hospital the next morning after the disease onset. Computed tomography (CT) showed free gas in the abdominal cavity, mediastinal emphysema, and subcutaneous pneumothorax. Upper gastrointestinal angiography showed that the esophageal mucosa was intact and the gastric antrum was perforated. Therefore, we chose to perform open gastric perforation repair on the patient under thoracic epidural anesthesia combined with intravenous anesthesia. An operative incision of the muscle layer of the patient's abdominal wall was made, and a large amount of subperitoneal gas was revealed. And a continued incision of the peritoneum revealed the presence of a perforation of approximately 0.5 cm in the gastric antrum, which we repaired after pathological examination. Postoperatively, the patient received high-flow oxygen and cough exercises. Chest CT was performed on the first and sixth postoperative days, and the mediastinal and subcutaneous gas was gradually reduced.
CONCLUSION
After gastric perforation, a large amount of free gas in the abdominal cavity can reach the mediastinum through the loose connective tissue at the esophageal hiatus of the diaphragm, and upper gastrointestinal angiography can clarify the site of perforation. In patients with mediastinal emphysema, open surgery avoids the elevation of the diaphragm caused by pneumoperitoneum compared to laparoscopic surgery and avoids increasing the mediastinal pressure. In addition, thoracic epidural anesthesia combined with intravenous anesthesia also avoids pressure on the mediastinum from mechanical ventilation.
Core Tip: Abdominal free gas from a perforated gastric ulcer may pass through the lax esophageal hiatus into the mediastinum and then travel up to the neck and chest wall. This condition should be differentiated from esophageal perforation, and upper gastrointestinal angiography can clarify the diagnosis. In such patients, the pneumoperitoneum for laparoscopic surgery increases the pressure in the abdominal cavity, not only causing elevation of the diaphragm but also allowing more gas to enter the mediastinum through the esophageal hiatus. Open surgery may be preferred. Thoracic epidural anesthesia combined with intravenous anesthesia can prevent the effect of mechanical ventilation on the mediastinum.
