Enteral feeding is a preferred route for postsurgical sustenance of very ill patients with a functioning small bowel.1,2 Postpyloric feeding through a jejunal tube is in wide practice and usually well tolerated. We report a case of small-bowel perforation related to a feeding jejunostomy tube.
A 76-year-old female was evaluated for symptoms of pruritis, painless jaundice, tea-coloured urine and yellow stools. An ampulary carcinoma was found via endoscopic retrograde cholangiopancreatography (ERCP). A pancreatoduodenectomy was performed, with insertion of a feeding jejunostomy tube. On the seventh postoperative day the patient had painful abdominal cramps.
Upon examination, her abdomen had tympany and severe tenderness in the right upper quadrant. Computed tomography of the abdomen and pelvis revealed marked thickening of the proximal small bowel distally near the jejunostomy site.
We did an emergency laparotomy and found wall necrosis with perforation, 100 cm distal to the tube insertion (Fig. 1). There was no evidence of intestinal strangulation or arterial occlusion. The necrotic edges of her bowel were immediately resected and sutured. The pathology report documented transmural necrosis and enteral nutrition impacted in the lumen (Fig. 2). The patient's further recovery was uneventful.
FIG. 1. Necrosis of the wall of the small intestine.
FIG. 2. Impacted enteral nutritive substance removed from the bowel.
The causative mechanism of this small- bowel perforation remains unclear, but the condition had many similarities to necrotizing enterocolitis, including systemic and mechanical factors. Hyperosmolarity, invasive bacterial overgrowth and massive bolus impaction were implicated for direct mucosal injury in this case, probably by intense local vasospasm, which could cause ischemic necrosis and perforation.
In cases of small-bowel obstruction, tube feeding should be discontinued immediately and total parenteral nutrition considered.3 Enteral nutrition has priority for nutritional support. When bowel obstruction occurs it is important to decide early whether surgical intervention is neccessary, for which decision abdominal CT, ultrasound and contrast radiography are useful.4,5
Competing interests: None declared.
Correspondence to: Dr. Nermin Halkic, Service de Chirurgie, 1011 Lausanne–CHUV, Switzerland; fax 41 21 314 23 60; nermin.halkic@chuv.hospvd.ch
Accepted for publication Mar. 3, 2004
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