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Infected aneurysm of thoracic aorta mimicking lower esophageal perforation in an elderly diabetic patient

However, it is rare that intestinal obstruction could be caused by a mechanism other than diffuse peritonitis, adhesion and volvulus during the early stage. In our search we could find only eight cases of intestinal obstruction during the early stage, such as those caused by the fixing for gastropexy, jejunal volvulus, gastroenteric fistula and hematoma. A case of transverse colon obstruction similar to ours improved quickly by removing the gastropexy stitches. Yokokawa et al. considered that the transverse colon was penetrated by stitches, and it caused intestinal obstruction in this case. However, this mechanism did not correspond to our case because the patient did not need stitches removing to improve the obstruction. We infer that she had transverse colon obstruction due to some other factors such as local colon hypokinesia by penetration/fixing of mesentery, slight localized peritonitis by PEG, and constipation. Thereafter the obstruction was improved due to the healing of the peritonitis, which was one of the factors. It is important for PEG to confirm plural methods, such as observing the focal invagination sign in the gastric wall, transillumination and test puncture, which are useful to avoid nonstomach injuries. However, we could not avoid penetration of the mesentery even though we had confirmed all of the tests. As the mesentery is thin and translucent, it may be difficult because of the problems of mesentery interposition between the abdominal and gastric wall. One report suggested that insertion of the endoscope in the left lateral position for PEG is useful for avoidance of mesentery penetration. Therefore, this could have been avoided if we had adopted the left lateral position instead of inserting the endoscope in the supine position. Other studies reported the usefulness of colonoscopy-assisted PEG for avoiding transverse colon injuries and gastroenteric fistulas, and it might be useful for avoiding not only transverse colon injury but also mesentery penetration. However, it is difficult to perform colonoscopy-assisted PEG in all cases that need gastrostomy because it may add to the burden on patients and endoscopists in comparison with ordinary PEG. To avoid nonstomach injury, we think that it is useful to adopt a left lateral position and colonoscopy-assisted PEG only for cases where there is a risk of mesentery penetration such as interposition of the bowel on the place to perform PEG and the presence of negative signs.