Teaching Case

37-year-old woman with a history of diabetis mellitus and endoscopic intragastric balloon insertion 5 months prior to presentation, presented with sudden onset of severe abdominal pain for 12 hours. It was intermittent and diffuse, then became constant and shifted to the left side with flatulence and nausea. Abdominal examination: distension, diffuse severe tenderness, rigidity, sluggish bowel sounds.

Contrast-enhanced computed tomography (CT) of the abdomen was performed, which revealed distended stomach, intraperitoneal free air mainly around the stomach, anterior to the gastric wall, with perforation (1 cm in size) in the stomach.
The intragastric balloon was 12 cm in diameter and inside the stomach.
Small amount of free fluid in the abdomen.

The patient was urgently taken to the operating room and underwent laparotomy.
At operation perforation (1 cm) in the anterior wall of the greater curvature of the stomach was found. This was compatible with the CT findings. The intragastric balloon was identified through the perforation. The balloon was punctured and removed through the perforation and the perforation was repaired by suturing the gastric wall.
The postoperative course was uneventful and the patient was discharged home on the sixth postoperative day.

Intragastric balloon (IGB) is a minimally invasive endoscopic procedure used for weight loss in obese patients. It is widely used in Western countries and the result of its use are variable and generally modest. [1, 2, 3]
Although most patients do not experience any complications and tolerate IGB well, IGB can sometimes be followed by complications.
Complications are usually mild like abdominal pain and nausea: theses are usually self-limiting after a short period.
Other complications are rare and severe like bowel obstruction after migration of the balloon, gastric perforation and death. [1, 2, 3, 4, 5]
Gastric perforation occurs in about 0.1% of cases and is a life-threatening complication that should be considered in acute abdomen in patients with IGB, even several weeks or months following IGB insertion. [1, 3, 5]
The mechanism of perforation is not yet well understood.
The balloon is supposed to be mobile inside the stomach and it is suggested that sometimes the balloon motility is reduced and results in continuous contact of the balloon with the gastric wall. This exerts constant pressure on the gastric mucosa with subsequent formation of an ulcer that could perforate. [1, 3, 4, 5]
Therefore the use of proton pump inhibitors (PPI) is recommended after IGB insertion. [3]
Our patient was maintaind on PPI, but she took them irregularily and stopped them 2 months prior to presentation.
Gastric perforation in diabetic patients can develop after acute gastric dilatation. Diabetic autoimmune neuropathy or acute change in blood sugar induce gastric hypomotility that leads to diabetic gastropareses and gastric dilatation that results in subsequent perforation. [1]
Since our patient had poor compliance to PPI and known diabetes mellitus, therefore both mechanisms are suggested as predisposing factors to perforation.
Imaging is mandatory to suggest the perforation in patients presenting with abdominal pain by revealing the presence of free air in the abdomen.
Both supine abdominal radiography and CT scanning are used.
CT scanning is more sensitive than plain radiography and is the current modality of choice.
It is used to localise the gas, detect any secondary signs like stranding in the mesenterium and sometimes showing the exact site of the defect. [6]
To our knowledge, this is the first reported case where the definitive diagnosis of gastric perforation after IGB insertion was made by CT scan.
The usual treatment is the removal of the balloon through the perforation via laparotomy or laparoscopy and repair of the gastric perforation.
Endoscopic IGB retrieval or combined laparoscopy with endoscopic IGB retrieval is also reported in the treatment. [4, 5]