Pneumoretroperitoneum, Pneumomediastinum, Pneumothorax, and Subcutaneous Emphysema after Diagnostic Colonoscopy

Abstract

Colonoscopy is a commonly performed endoscopic procedure. Although it is generally considered to be safe, serious complications, such as colorectal perforation, can occur. Most colonic perforations are intraperitoneal and cause pneumoperitoneum with acute abdominal pain as the initial symptom. However, extraperitoneal perforations with pneumoretroperitoneum may happen, albeit rarely, with atypical initial symptoms. We report a rare case of rectosigmoid perforation occurring after diagnostic colonoscopy that developed into pneumoretroperitoneum, pneumomediastinum, pneumothorax, and subcutaneous emphysema, with a change in voice and neck swelling as the initial symptoms. The patient was successfully treated with endoscopic closure of the perforation and conservative management. (Korean J Gastroenterol 2017;70:145-149)

Pneumoretroperitoneum, pneumomediastinum, pneumothorax and subcutaneous emphysema after diagnostic colonoscopy

“…On physical examination, decreased respiratory sounds in the left hemithorax and subcutaneous emphysema on cervical area was obtained. The pathophysiological mechanism of subcutaneous emphysema and pneumomediastinum might be explained due to the presence of a visceral space, which goes from the neck through the mediastinum and retroperitoneum [4][5][6][7][8]. This visceral space follows the trachea and esophagus along the chest and creates a tract for air.…”

“…The space continues inferiorly through the diaphragmatic hiatus and reaches to the retroperitoneum [4][5][6][7][8].…”

“…When air enters the retroperitoneum, it rises by pressure effect along the fascial planes, follows the large vessels, progress through the diaphragmatic hiatus, and reaches to the mediastinum and subcutaneous neck tissues [4][5][6][7][8][9][10]. Large amount of air may leak from the mediastinal pleura to the pleural cavity [5,8,9].…”

“…Accompanied by clinical findings, it has been reported that sub-diaphragmatic air in abdominal radiography is an important sign and can be diagnosed in approximately 87% of cases [2]. Chest radiography may also be helpful in cases who present with pneumothorax [3][4][5][6][7]. Abdominal computed tomography may provide information about the location of perforation [1][2][3][4][5].…”

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

“…Only one case reported pneumothorax and three extraperitoneal perforation after diagnostic colonoscopy. These cases were treated with conservative therapy of bowel rest, total parenteric nutrition (TPN), endoscopic repair, or laparotomy with anastomosis [9][10][11][12]. Other extraperitoneal manifestations, such as subcutaneous emphysema and mediastinal air, result from communication of fascial planes, mostly near large vessels that connect with cervical soft tissue between the mediastinum and retroperitoneum [6,13].…”