GAP-112
Emergence emesis of duodenogastric reflux in a patient with an endoscopically visualized empty stomach
Stalls C, Falcon R, Petersen T, Soneru C
University of New Mexico, Albuquerque, NM, United states
Transpyloric reflux of duodenal contents, including bile acid and pancreatic enzymes, routinely occurs in small volumes as physiologic pressure gradients across the pylorus shift during digestive stages or in response to endoscopy. We report a case of large duodenogastric reflux (DGR) and emesis during emergence despite known empty stomach.
A 3-year-old, 15.3-kg boy with history of short bowel syndrome s/p small bowel transplant presented for EGD evaluation of blood in his stool. The child was appropriately NPO and was induced with fentanyl, propofol, and rocuronium with uneventful placement of endotracheal tube. The stomach was easily visualized on endoscopy to be empty and with closed pylorus. However, during stage 2 of emergence, the patient vomited ~150cc of dark, bilious fluid. Once the stomach was suctioned again and the patient fully awake, the cuff of the ETT was deflated and the patient was extubated without complication. The patient remained at his pre-operative respiratory status in the recovery room, maintaining SpO2 of 98% on room air.
In one study of 1120 children, 8.2% (92) were found to have DGR on endoscopy; in small volume, it is regarded as a physiologic finding. The clinical significance of the effect of DGR on gastric mucosa is somewhat controversial, though the serious consequences of aspiration and subsequent acute lung injury are well described. When bile-rich reflux is aspirated into the lungs, studies demonstrate induction of acute cellular injury with subsequent “bile pneumonia†and increased A-a gradient through unclear pathophysiology. The risk for high volume bilious aspiration in appropriately NPO patients may be greater in those children with structural derangements or dysmotility of the upper GI tract. These patients, such as the one discussed above, are at increased risk for perioperative aspiration of DGR and would likely benefit from additional anesthetic precautions.
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