Gastric Perforation, a Rare Consequence of Unintentional Esophageal Intubation

Mobin Faghih Soleimani; Ali Yamini; Ehsan Amiri; Saman Khosronejad

doi:10.18502/crcp.v8i4.14579

Mobin Faghih Soleimani Medical Student, Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
Ali Yamini Assistant Professor of Surgery, Ward of Surgery, Besat Hospital, Hamadan, Iran
Ehsan Amiri Medical Student, Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
Saman Khosronejad Medical Student, Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran

DOI: https://doi.org/10.18502/crcp.v8i4.14579

Keywords: Intubation; Complication; Esophageal intubation; Gastric perforation

Abstract

Accidental esophageal intubation is a preventable human error that complicates airway management and continues to occur despite advances in medical devices. Perforation of the stomach has been associated with esophageal intubation in several case reports. This report presents a case of an elderly woman suspected of having COVID-19-related pneumonia. She was intubated due to respiratory dysfunction. In the initial few minutes, the patient became desaturated, leading to a second intubation. An hour later, the patient’s abdomen was distended, and the chest computed tomography (CT) showed a massive pneumoperitoneum. During laparotomy, a 6 cm long rupture was found in the lesser curvature, which was attributed to accidental esophageal intubation. To avoid such a fatal condition, it is imperative for physicians to ensure the correct positioning of the endotracheal tube. To achieve this goal, further investigation into readily available and highl y sensitive techniques is recommended.