Bowel perforation due to break and distal passage ofthe safety ring of an adjustable intra-gastric balloon： Apotentially life threatening situation

A 45-year-old man of Middle Eastern origin, morbidobese, with a body mass index of 39 had an intragastricballoon, filled with 500 mL of saline/methyleneblue and intended as definite therapy, inserted some8 wk previously. He was admitted to the emergencydepartment with abdominal cramps. An ultrasound ofthe abdomen was performed in ER which confirmedthe balloon to be in place without any abnormality.He was discharged home on symptomatic medication.Patient remains symptomatic therefore he reportedback to ER 2 d later. Computed tomography scanwas performed this time for further evaluation whichrevealed a metallic ring present in the small bowelwhile the intra-gastric balloon was in its proper position.There was no clinical or radiological sign of intestinalobstruction. Patient was hospitalized for observationand conservative management. The following night,patient experienced sudden and severe abdominalpain, therefore an X-ray of the abdomen in erectposition was done, which showed free air under theright dome of diaphragm. Patient was transferred toO.R for emergency laparotomy. There were two smallperforations identified at the site of the metallic ringentrapment. The ring was removed and the perforationswere repaired. Due to increasing prevalence of obesityand advances in modalities for its management,physicians should be aware of treatment options, theirbenefits, complications and clinical presentation of theknown complications. Physicians need to be updated toapproach these complications within time, to avoid lifethreateningsituations caused by these appliances.