To the Editor:—
An 85-yr-old man was transferred to our institution for evacuation of a subdural hematoma. His course was complicated by deep venous thromboembolism necessitating intravenous heparin. He ultimately required intubation and was ventilated for several minutes before the recognition of an inadvertent esophageal intubation. The endotracheal tube was correctly repositioned, and a nasogastric tube was inserted with the return of approximately 500 ml of fresh blood. After the heparin was discontinued, his partial thromboplastin time normalized, and the platelet count and international normalized ratio were also normal. On upper endoscopy, the esophagus and duodenum were completely normal. In the gastric fundus, there were linear mucosal tears (fig. 1). There was no surrounding inflammation, and the appearance was not consistent with trauma from the nasogastric tube. There was minimal oozing of blood and small adherent clots, but there was nothing necessitating endoscopic treatment.
Tears in the gastric mucosa from overdistension during endoscopy for percutaneous endoscopic gastrostomy tube placement in the setting of malnutrition, advanced age, and gastric atrophy have been described.1Gastric perforation from overdistention has been reported in patients undergoing cardiopulmonary resuscitation2,3and inadvertent esophageal intubation.4–8In these cases of iatrogenic gastric rupture, rapid accumulation of air leads to mucosal tears and ultimately to rupture of the stomach. At laparotomy or autopsy, the defect is typically identified in the lesser curvature of the stomach (the area of least elastance).8Rapid gastric distention may cause compression of the cardia by the right hemidiaphragm and also alter the angle of the antrum.9These changes allow air entry through the gastroesophageal junction but prevent escape of air through the gastroesophageal junction or the pylorus.8,9
We report a case of acute upper gastrointestinal bleeding from mucosal tears resulting from gastric overdistention after inadvertent esophageal intubation. To our knowledge, this complication has not been previously described and should be included in the differential diagnosis of upper gastrointestinal bleeding in critically ill patients who have had inadvertent esophageal intubation or cardiopulmonary resuscitation. The combination of history of esophageal intubation, involvement of the lesser curvature, and similarity to the mucosal tears seen by Green and Tendler1during percutaneous endoscopic gastrostomy tube placement support this diagnosis. In addition, in cases of upper gastrointestinal bleeding when a history of inadvertent esophageal intubation is obtained, gastric perforation should be ruled out with abdominal imaging before performing upper endoscopy.
*University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. email@example.com