Six weeks before transferal to our university hospital for treatment of direct ARDS, the patient was admitted to a local hospital due to epigastric pain during indwelling of a 6-month-old IGB. The IGB therapy led to a total weight loss of 5 kg body weight with a reduction of the body mass index from 29.7 to 27.9. After diagnosing free abdominal air (Fig. 1), the IGB was removed by an outpatient endoscopy. No further diagnostics or treatment were performed.
Following removal of the IGB, the patient developed increasing pain of the left shoulder. Under the suspicion of subacromial bursitis, the patient was treated with corticosteroids for a period of 10 days. Several days later, the patient became symptomatic with progressive dyspnea. CT-scan of the chest revealed pneumonia with abscess of the left lower lobe. Due to rapidly deteriorating hypoxemic lung failure the patient necessitated orotracheal intubation and mechanical ventilation. Based on a PaO2/FIO2 ratio of 86 mmHg at PEEP-level of 10 mbar and peak inspiratory pressure of 28 mbar within 12 h after intubation, the patient was presented to our hospital for evaluation of veno-venous extracorporeal lung support (vvECMO). Diagnostic work-up of previous free intraabdominal air, pain of the left shoulder and pneumonia with abscess in a young, otherwise immunocompetent patient led to the diagnosis of a perforation of the posterior wall of the gastral antrum (Fig. 2), resulting in a left subphrenic abscess with destruction of the diaphragm and development of pneumonia per continuitatem (Fig. 3). With proof of both, gastric perforation and staphylococcus subspecies in the abscess drainage, empiric antibiotic treatment with piperacilline / tazobactame, clarithromycine and cefazoline was changed to caspofungin, vancomycin and cefazolin. The gastric perforation could be visualized endoscopically and successfully be closed by use of an over-the-scope-clip. During a repeated CT-scan, a pigtail drainage was percutaneously inserted under radiological guidance and was used as a suction-irrigation drainage. This drainage allowed timely resolution of the infradiaphragmatic abscess. Despite rapid diagnosis of the underlying disease process and despite successful endoscopic closure of the perforated stomach, advanced destruction of the left-sided diaphragm and alveolar spaces of the left lower lobe led to persistent, extensive air-leakage and finally inadequate alveolar ventilation. Beside lung-protective ventilatory strategies with high PEEP, inverse ratio ventilation and low tidal volumes, the subsequent progressive hypoxemic lung failure necessitated mechanical support by means of bifemoral vvECMO for a period of 15 days and subsequently further mechanical ventilation to maintain adequate oxygenation. Due to the underlying extensive air-leakage, adjunctive therapy strategies such as inhaled nitric oxide or prone positioning have not been attempted. ARDS was successfully treated and the patient was discharged in a good clinical condition and without any neurological sequel after six weeks.