Intraperitoneal and Extraperitoneal Colonic Perforation Following Diagnostic and Therapeutic Colonoscopy with Crohn’s-related Stricture Dilation

Abstract

Colonic perforation is an uncommon but known and feared complication of colonoscopy, which carries a high mortality rate. We present an uncommon case of extensive intra-and extraperitoneal air following colonic perforation in a patient undergoing inpatient colonoscopy for evaluation of unintentional weight loss and constipation. During colonoscopy, a splenic flexure stricture was identified and dilated. Postprocedural hemodynamic instability prompted further imaging which revealed pneumoperitoneum, bilateral pneumothorax, pneumomediastinum, pneumopericardium, and severe subcutaneous emphysema. Emergent exploratory laparotomy found perforation of the proximal transverse colon which required resection and transverse colostomy placement. The patient also underwent bilateral chest tube placement and was treated with antibiotics for peritonitis. The patient was eventually diagnosed with Crohn's disease and discharged to an extended care facility with outpatient follow-up. Extraperitoneal colonic perforations are fairly rare, and to our knowledge, we present the most severe case that has been published in recent years.

Management of Enterocutaneous Fistula in Crohn’s Disease by Embolization With Glue Injection and Coiling: A Case Report

“…ICP management is tailored to each patient's unique situation and may be conservative, endoscopic, or surgical, with the potential for various surgical techniques [ 16 ]. Weng et al reported a case in which a CD patient had perforation following an endoscopy and was treated surgically with bowel resection at the site of perforation due to the instability exhibited in the patient's status and the extensive complications following ICP [ 17 ].…”

Colonic perforation revealed by massive subcutaneous emphysema

“…[ 4 ] Few cases reported the presence of SE after colonic perforation complicating colonoscopy. [ 2 3 ] Colonic perforation is a rare complication of colonoscopy with an incidence ranging from 0.04% to 0.7% . 2 It can lead to SE only if the perforation involves the extraperitoneal colon.…”

“…[ 1 ] In rare occasions, SE may occur after extraperitoneal colonic perforation following colonoscopy. [ 2 3 ] However, this rare presentation of colonic perforation, particularly without suggestive medical history, may delayed the diagnosis of this life-threatening condition. Informed consent from the patient's family was obtained before writing this case report.…”