Massive Pneumoperitoneum from Barogenic Gastric Injury Complicating Difficult Mask Ventilation: A Case Report

Abstract

Background: Gastric insufflation during airway management is common, but progression to gastric wall injury with pneumoperitoneum is rare. This report describes a case of massive pneumoperitoneum caused by barogenic gastric injury after difficult mask ventilation during an elective procedure performed under sedation. Case Presentation: A 55-year-old woman with a history of three previous abdominopelvic operations for uterine leiomyoma underwent direct laryngoscopy under sedation for a left vocal-fold polyp. The procedure was complicated by oxygen desaturation, requiring prolonged bag-mask ventilation and several intubation attempts before the airway was secured. Marked abdominal distension developed and did not resolve after nasogastric aspiration. Thoraco-abdomino-pelvic computed tomography demonstrated a large-volume pneumoperitoneum, and the patient was transferred for emergency surgical management. On arrival, she was haemodynamically stable, with diffuse abdominal distension and tympany. Diagnostic laparoscopy confirmed pneumoperitoneum and revealed three serosal lacerations of the stomach, each approximately 3 cm long. There was no peritoneal effusion, and the colon and small bowel were intact. A methylene-blue leak test was negative, indicating no demonstrable full-thickness gastric leak at the time of surgery. The gastric lacerations were repaired with simple interrupted 2-0 polyglactin sutures. The postoperative course was uneventful, bowel transit resumed by the third postoperative day, and the patient was discharged in good condition on the fourth postoperative day. Conclusion: Acute abdominal distension after difficult mask ventilation or repeated intubation attempts should prompt suspicion of barogenic gastric injury. Even when intraoperative leak testing is negative, partial-thickness gastric tears may be clinically significant and warrant careful inspection and repair.