Cerebral air embolism as a complication of peptic ulcer in the gastric tube: case report
© Suzuki et al; licensee BioMed Central Ltd. 2011
Received: 30 June 2011
Accepted: 21 December 2011
Published: 21 December 2011
The reported incidence of ulcer formation in the gastric tube in esophageal replacement is rare.
This is the first report of a case of cerebral air embolism as a result of spontaneous perforation of an ulcer in the constructed gastric tube into the pulmonary vein during post-operative follow-up in a patient with esophageal cancer.
Cerebral air embolism is a rare complication of penetrating gastric ulcer, but should be considered in patients with a history of esophagectomy with gastric conduit that present with acute neurologic findings.
The reported incidence of ulcer formation in the gastric tube in esophageal replacement ranges from 2.6%-19.4% [1, 2]. Here, we describe the first report of a case of cerebral air embolism as a result of spontaneous perforation of a gastric tube ulcer into the pulmonary vein. This case highlights the importance of ongoing awareness of the risk of recurrence of peptic ulcers in the constructed gastric tube during post-operative follow-up in patients with esophageal cancer.
Several etiological mechanisms for the formation of gastric tube ulcers have been postulated, including hypersecretion of gastric juice, inadequate drainage from the pylorus, and breakdown of the mucous and mucosal barrier as a result of disturbed vascular circulation of the gastric tube . In our case, gastric pedicle stasis in the eight years after surgery due to denervation or the gastric tube itself may have caused delayed gastric emptying, with a resulting increase in gastrin secretion and high acidity. Peptic ulcer of the gastric tube may penetrate into any adjacent organ , including the right pleural cavity , bronchi , pericardial cavity , thoracic aorta , pulmonary artery , left brachiocephalic vein , and sternum . Cerebral air emboli are usually caused by trauma or an invasive procedure, including upper gastrointestinal endoscopy , affecting one of the blood vessels. In the present case, however, the patient had no trauma, invasive procedures, or central line access. To our knowledge, this is the first reported case of cerebral air embolism resulting from spontaneous perforation of a gastric tube ulcer into the pulmonary vein.
Cerebral air embolism is a rare complication of penetrating gastric ulcer, but should be considered in patients with a history of esophagectomy with gastric conduit that present with acute neurologic findings. Postoperative endoscopic surveillance should be considered based on the risk-benefit profile and clinical symptoms of each individual patient.
Written informed consent was obtained from the patient's relatives for publication of this case report.
All authors are specialized in diagnoses and treatments for all diseases occurring from both upper and lower gastrointestinal tract (esophagus, stomach, intestine, colon). TA and HG also are working on clinical and basic research for all diseases occurring from both upper and lower gastrointestinal tract. Research projects of TA and HG include Clinical and Basic Research for advanced endoscopic therapy, Clinical Research for Ultra-Zoom Endoscopy, Molecular Biological Research on GISTs, Clinical Research for EUS-Elastography, Helicobacter pylori Infection and Gastric cancer, Gastroesophageal reflux disease, Barrett's esophagus, and Esophageal adenocarcinoma.
- Koide N, Hiraguri M, Nishio A, Hanazaki K, Adachi W, Shikama N, Oguchi M, Maezawa T, Amano J: Ulcer in the gastric tube for esophageal replacement: a comparison of 12 esophageal cancer patients with or without postoperative radiotherapy. J Gastroenterol Hepatol. 2001, 16: 137-41. 10.1046/j.1440-1746.2001.02415.x.View ArticlePubMedGoogle Scholar
- Uchida Y, Tomonari K, Murakami S, Hadama T, Shibata O, Shirabe J: Occurrence of peptic ulcer in the gastric tube used for esophageal replacement in adults. Jpn J Surg. 1987, 17: 190-4. 10.1007/BF02470598.View ArticlePubMedGoogle Scholar
- Shima I, Kakegawa T, Fujita H, Yamana H, Shirouzu G, Minami T, Toh Y, Nishida H, Sueyoshi S: Gastropericardial and gastrobrachiocephalic vein fistulae caused by penetrating ulcers in a gastric pedicle following esophageal cancer resection: a case report. Jpn J Surg. 1991, 21: 96-9. 10.1007/BF02470872.View ArticlePubMedGoogle Scholar
- Piessen G, Lamblin A, Triboulet JP, Mariette C: Peptic ulcer of the gastric tube after esophagectomy for cancer: clinical implications. Dis Esophagus. 2007, 20: 542-5. 10.1111/j.1442-2050.2007.00706.x.View ArticlePubMedGoogle Scholar
- Peters JL, Fisher C, Kenning BR, Pye JK: Late benign intrathoracic gastric perforation after oesophagectomy for carcinoma. Br Med J (Clin Res Ed). 1981, 282: 1512-13.View ArticleGoogle Scholar
- McDermott M, Hourihane DO: Fatal non-malignant ulceration in the gastric tube after oesophagectomy. J Clin Pathol. 1993, 46: 483-5. 10.1136/jcp.46.5.483.View ArticlePubMedPubMed CentralGoogle Scholar
- Matsubara T: Purulent pneumopericarditis due to ulcer of the retrosternal stomach roll after esophagectomy. Eur J Cardiothorac Surg. 2002, 22: 1007-10.1016/S1010-7940(02)00564-X.View ArticlePubMedGoogle Scholar
- Takebayashi T, Okushiba S, Ohno K, Ito K, Sato K, Morikawa T, Kondo S, Katoh H: Peptic ulcer-induced acute aortogastric fistula occurring 7 years after a pharyngogastrostomy following a resection for carcinoma of the esophagus: report of a case. Surg Today. 2004, 34: 777-9.View ArticlePubMedGoogle Scholar
- Aiko S, Ando N, Shinozawa Y, Ozawa S, Kitajima M, Kurose I, Tsuchiya M: Increased chemiluminescence and ulcer development in the low blood flow state of the gastric tube for esophageal replacement. J Clin Gastroenterol. 1993, 17: S161-6.View ArticlePubMedGoogle Scholar
- ter Laan M, Totte E, van Hulst RA, van der Linde K, van der Kamp W, Pierie JP: Cerebral gas embolism due to upper gastrointestinal endoscopy. Eur J Gastroenterol Hepatol. 2009, 21: 833-5. 10.1097/MEG.0b013e328310aefc.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/11/139/prepub
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