ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Grace Elta and Robert J. Fontana, Section Editors
Acute Dyspnea During Diagnostic Sigmoidoscopy Qiyuan Qin, Tenghui Ma, and Lei Wang Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
Question: A 29-year-old man presented with a 3-month history of intermittent diarrhea with tenesmus. He was diagnosed with Crohn’s disease and underwent subtotal colectomy and ileosigmoidostomy at an outside institution 4 years before. Sulfasalazine and mesalazine were irregularly taken during past 4 years. He denied fever, melena, hemafecia, and abdominal pain. Abdominal palpation revealed a hard and painless mass of limited motion in the left lower quadrant. Digital examination revealed the stricture of rectum. Laboratory examination was unremarkable except for erythrocyte sedimentation rate of 17 mm/h. Abdominal computed tomography (CT) was performed (Figure A, B). Sigmoidoscopy was performed with the patient sedated intravenously. The endoscope was carefully introduced and passed the anastomosis. Serpiginous ulcers were noted in sigmoid colon and terminal ileum. At this point, the patient developed acute dyspnea and profound swelling of the neck with decreasing oxygen saturation. The procedure was terminated immediately and the patient was transferred to our intensive care unit. Physical examination revealed clear crepitus in the neck and decreased breath sounds of right-sided chest. The abdomen was soft and nontender. Laboratory investigation showed leukocytosis of 14.86 109/L and C-reactive protein of normal level. Bedside chest radiography (Figure C) revealed extensive subcutaneous emphysema and right-sided pneumothorax of 50% (white arrows), pneumoperitoneum, and pneumoretroperitoneum (black arrows). Oxygen therapy and tube thoracostomy under water-seal drainage was quickly undertaken. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.09.054
Gastroenterology 2014;146:e1–e3
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1: Sigmoideum Fistula and Pneumotosis Intestinalis CT of the chest and abdomen was performed again 3 days after tube thoracostomy, revealing limited bilateral hydropneumothoraces (Figure D, black arrows), pneumomediastinum (Figure D, white arrows), and massive free air intra- and retroperitoneally (Figure E). Abdominal CT at both times showed intraperitoneal abscesses adjacent to sigmoid colon (Figure A, B, F) and the later scan revealed intramural gas in the wall of sigmoid colon (Figure G). These findings are suggestive of sigmoideum fistula and pneumotosis intestinalis (PI) subsequent to sigmoidoscopy. The patient was managed conservatively with oxygen therapy, antibiotics, parenteral and enteral alimentation, and recovered uneventfully 3 weeks later. Diagnostic colonoscopy is regarded as a safe procedure. Massive air leakage with full body involvement after colonoscopy is an extremely rare complication, which generally occurs in the context of therapeutic colonoscopy.1 Inflammatory bowel disease (IBD) is a risk factor for adverse events with colonoscopy. Crohn’s disease, characterized by transmural inflammation and granulomatous lesions of intestinal mucosa, is complicated with internal fistulas in 5%–10% of patients. Asymptomatic fistula is usually not an indication for aggressive treatments, where lack of attention potentiates iatrogenic injuries. PI, defined as dissection of air in the bowel wall, is idiopathic or secondary to both gastrointestinal and nongastrointestinal diseases, including IBD, intestinal ischemia, infectious enteritis, chronic obstructive pulmonary disease, connective tissue disorders, and drug therapy.2 The symptoms of large intestine PI include diarrhea, abdominal pain, distention, and constipation. Physical examination could be normal except for occasionally palpable mass on abdominal or digital examination. PI complicated by free air leakage is very uncommon in patients with IBD. No case of air leakage involving abdomen, chest, and neck accompanying PI has been reported previously. In our patient, both sigmoideum fistula and PI contributed to the rapid and massive extraluminal air leakage during the diagnostic sigmoidoscopy, resulting in acute dyspnea and unstable vital signs. Air passed into the peritoneal cavity through fistula directly and might decompress into the pleural space through small diaphragmatic fenestrations. PI was responsible for the air passage along mesentery to the retroperitoneum and subsequent travel along the facial planes to mediastinum. The rupture of pleura caused pneumothorax and subcutaneous emphysema.3 Asymptomatic fistula in patients with Crohn’s disease entails vigilance against profound air leakage with full body involvement during diagnostic colonoscopy. Without clinical signs of intestinal perforation or necrosis, air leakage may not require operative intervention.
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ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI References 1. 2. 3.
Bouma G, van Bodegraven AA, van Waesberghe JH, et al. Post-colonoscopy massive air leakage with full body involvement: an impressive complication with uneventful recovery. Am J Gastroenterol 2009;104:1330–1332. Schneider JA, Adler DG. Pneumatosis coli in the setting of severe ulcerative colitis: a case report. Dig Dis Sci 2006; 51:185–191. Zeno BR, Sahn SA. Colonoscopy-associated pneumothorax: a case of tension pneumothorax and review of the literature. Am J Med Sci 2006;332:153–155.
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Acute Dyspnea During Diagnostic Sigmoidoscopy Qiyuan Qin, Tenghui Ma, and Lei Wang Department of Colorectal Surgery, Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
Question: A 29-year-old man presented with a 3-month history of intermittent diarrhea with tenesmus. He was diagnosed with Crohn’s disease and underwent subtotal colectomy and ileosigmoidostomy at an outside institution 4 years before. Sulfasalazine and mesalazine were irregularly taken during past 4 years. He denied fever, melena, hemafecia, and abdominal pain. Abdominal palpation revealed a hard and painless mass of limited motion in the left lower quadrant. Digital examination revealed the stricture of rectum. Laboratory examination was unremarkable except for erythrocyte sedimentation rate of 17 mm/h. Abdominal computed tomography (CT) was performed (Figure A, B). Sigmoidoscopy was performed with the patient sedated intravenously. The endoscope was carefully introduced and passed the anastomosis. Serpiginous ulcers were noted in sigmoid colon and terminal ileum. At this point, the patient developed acute dyspnea and profound swelling of the neck with decreasing oxygen saturation. The procedure was terminated immediately and the patient was transferred to our intensive care unit. Physical examination revealed clear crepitus in the neck and decreased breath sounds of right-sided chest. The abdomen was soft and nontender. Laboratory investigation showed leukocytosis of 14.86 109/L and C-reactive protein of normal level. Bedside chest radiography (Figure C) revealed extensive subcutaneous emphysema and right-sided pneumothorax of 50% (white arrows), pneumoperitoneum, and pneumoretroperitoneum (black arrows). Oxygen therapy and tube thoracostomy under water-seal drainage was quickly undertaken. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2013.09.054
Gastroenterology 2014;146:e1–e3
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1: Sigmoideum Fistula and Pneumotosis Intestinalis CT of the chest and abdomen was performed again 3 days after tube thoracostomy, revealing limited bilateral hydropneumothoraces (Figure D, black arrows), pneumomediastinum (Figure D, white arrows), and massive free air intra- and retroperitoneally (Figure E). Abdominal CT at both times showed intraperitoneal abscesses adjacent to sigmoid colon (Figure A, B, F) and the later scan revealed intramural gas in the wall of sigmoid colon (Figure G). These findings are suggestive of sigmoideum fistula and pneumotosis intestinalis (PI) subsequent to sigmoidoscopy. The patient was managed conservatively with oxygen therapy, antibiotics, parenteral and enteral alimentation, and recovered uneventfully 3 weeks later. Diagnostic colonoscopy is regarded as a safe procedure. Massive air leakage with full body involvement after colonoscopy is an extremely rare complication, which generally occurs in the context of therapeutic colonoscopy.1 Inflammatory bowel disease (IBD) is a risk factor for adverse events with colonoscopy. Crohn’s disease, characterized by transmural inflammation and granulomatous lesions of intestinal mucosa, is complicated with internal fistulas in 5%–10% of patients. Asymptomatic fistula is usually not an indication for aggressive treatments, where lack of attention potentiates iatrogenic injuries. PI, defined as dissection of air in the bowel wall, is idiopathic or secondary to both gastrointestinal and nongastrointestinal diseases, including IBD, intestinal ischemia, infectious enteritis, chronic obstructive pulmonary disease, connective tissue disorders, and drug therapy.2 The symptoms of large intestine PI include diarrhea, abdominal pain, distention, and constipation. Physical examination could be normal except for occasionally palpable mass on abdominal or digital examination. PI complicated by free air leakage is very uncommon in patients with IBD. No case of air leakage involving abdomen, chest, and neck accompanying PI has been reported previously. In our patient, both sigmoideum fistula and PI contributed to the rapid and massive extraluminal air leakage during the diagnostic sigmoidoscopy, resulting in acute dyspnea and unstable vital signs. Air passed into the peritoneal cavity through fistula directly and might decompress into the pleural space through small diaphragmatic fenestrations. PI was responsible for the air passage along mesentery to the retroperitoneum and subsequent travel along the facial planes to mediastinum. The rupture of pleura caused pneumothorax and subcutaneous emphysema.3 Asymptomatic fistula in patients with Crohn’s disease entails vigilance against profound air leakage with full body involvement during diagnostic colonoscopy. Without clinical signs of intestinal perforation or necrosis, air leakage may not require operative intervention.
e2
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI References 1. 2. 3.
Bouma G, van Bodegraven AA, van Waesberghe JH, et al. Post-colonoscopy massive air leakage with full body involvement: an impressive complication with uneventful recovery. Am J Gastroenterol 2009;104:1330–1332. Schneider JA, Adler DG. Pneumatosis coli in the setting of severe ulcerative colitis: a case report. Dig Dis Sci 2006; 51:185–191. Zeno BR, Sahn SA. Colonoscopy-associated pneumothorax: a case of tension pneumothorax and review of the literature. Am J Med Sci 2006;332:153–155.
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