JSCR 2013; 12 (3 pages) doi:10.1093/jscr/rjt118
Case Report
Surgical emphysema following therapeutic colonoscopy Jason Ramsingh*, Ahmad Ali, Ahmed Al-Ani and Gerrit Denys Department of General Surgery, Inverclyde Royal Hospital, Greenock, UK, *Correspondence address. Department of General Surgery, Inverclyde Royal Hospital, Greenock, UK. E-mail: [email protected] Received 22 October 2013; revised 17 November 2013; accepted 18 November 2013
Colonoscopy is an invasive procedure used in the detection of colon cancer, inflammatory bowel disease and investigation of bleeding from the rectum. In addition to diagnostic procedures, colonoscopy also has therapeutic indications such as polypectomy and dilation of strictures. We present a case of a patient who presented with cervical emphysema following a therapeutic colonoscopy. The patient had no abdominal or chest pain, shortness of breath and was managed conservatively. Perforation following colonoscopy is a rare complication; however, it is essential that doctors recognize and are aware of the different presentations and management options for this complication.
INTRODUCTION Colonoscopy is used in the evaluation of diseases affecting the lower gastrointestinal tract. Being an invasive procedure, it is associated with complications that can be managed conservatively or require surgical intervention. In our case report, we discuss a patient who developed surgical emphysema following a therapeutic colonoscopy without any associated abdominal or chest symptoms and was managed conservatively. This case report highlights one of the rare presentations of colonoscopic perforations and provides a feasible management option for clinicians.
CASE REPORT A 60-year-old female presented to our endoscopy suite after being referred by her general practitioner for investigation of bleeding and passage of mucus per rectum. She also complained of tenesmus and reduced appetite but no weight loss. Her past medical history included being diagnosed with ulcerative colitis 26 years ago during her first pregnancy for which she was treated with steroids and has been relatively healthy since then. She had a previous colonoscopy in 2008, following a positive bowel screening. This colonoscopy showed quiescent colitis confirmed by biopsy. During the present colonoscopy, she had biopsies taken from her rectum, sigmoid, descending and ascending colon given the findings of pseudopolyps.
After her procedure she complained of swelling in her neck. This was not accompanied by shortness of breath, chest pain or abdominal pain. On examination, her oxygen saturation was 99% on room air, with normal respiratory and heart rate. Her respiratory examination was normal and her abdomen was soft and non-tender. She had marked crepitus over her clavicles, supraclavicular fossa and most of her neck. Her erect chest X-ray revealed air under both hemidiaphragms and significant pneumomediastinum (Fig. 1). A computed tomography (CT) scan of her chest, abdomen and pelvis was requested. This CT-scan revealed very extensive spreading of surgical emphysema in the retroperitoneum, extending into the mediastinum with small volumes of free intraperitoneal gas (Figs 2 – 4). The patient was admitted and managed conservatively. This consisted of keeping her nil by mouth for 24 h, intravenous fluids and antibiotics. Her cervical emphysema gradually resolved and she was discharged 72 h after presentation without any surgical intervention.
DISCUSSION The rate of perforation following colonoscopy ranges from 0.03 to 0.12% [1, 2]. Perforations can occur from three different mechanisms [3]. First, it can result from mechanical perforation with the colonoscope and is usually recognized at the time of endoscopy. Secondly, it can occur as a result of
Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. # The Author 2013. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by-nc/3.0/), which permits non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected].
Page 2 of 3
J. Ramsingh et al.
Figure 4. CT scan of chest showing an extensive pneumomediastinum. Figure 1. Chest X-ray illustrating pneumoperitonuem, pneumomediastinum and cervical emphysema.
Figure 2. CT scan showing an extensive pneumoretroperitoneum.
Figure 3. CT scan of abdomen showing free intraperitoneal gas compressing the splenic flexure.
overzealous air insufflation or barotrauma. Lastly, it can occur after therapeutic procedures such as polypectomies and biopsies. Various authors have identified significant risk factors for perforation. Arora et al. [4] reported that advanced age, significant comorbidity, obstruction as an indication for colonoscopy and performance of invasive interventions increased
the risk of perforation. Rabeneck et al. [5] also reported that older age, male sex, having a polypectomy and a low volume endoscopic service increased the risk of perforation. Our patient presented after a therapeutic colonoscopy with cervical emphysema as the initial complaint without any abdominal or chest complaints even though her imaging revealed both pneumoperitoneum and pneumomediastinum. Fortunately, she did not exhibit signs of the fourth pneumothorax and did not require a chest drain. This is in stark contrast to previously published case reports where patients developed pneumothoraces requiring chest tube drainage [6, 7]. Maunder et al. [8] has described the path taken by air in the retroperitoneum into the mediastinum. Briefly, air in the retroperitoneum can track upwards entering the mediastinum via the hiatus for the aorta and IVC. The air can then continue along fascial planes into the neck resulting in cervical emphysema. Additionally, air within the peritoneum can enter the mediastinum via the oesophageal hiatus or can pass through openings in the diaphragm to enter the pleural cavity resulting in pneumothorax [9]. Conservative management of perforation following colonoscopy is a safe and acceptable option in patients not exhibiting signs of peritonitis, adequate bowel preparation or silent perforations. Additionally, perforations resulting from therapeutic procedures are usually small and are best managed conservatively [10]. Perforation following colonoscopy is a known but fortunately rare complication. Being aware of the various presentations and management options will improve clinical care.
REFERENCES 1. Cobb WS, Heniford BT, Sigmon LB, Hasan R, Simms C, Kercher KW, et al. Colonoscopic perforations: incidence, management, and outcomes. Am Surg 2004;70:750– 7; discussion 757 –758. 2. Korman LY, Overholt BF, Box T, Winker CK. Perforation during colonoscopy in endoscopic ambulatory surgical centers. Gastrointest Endosc 2003;58:554– 7. 3. Damore LJ, Rantis PC, Vernava AM, Longo WE. Colonscopic perforations. Etiology, diagnosis and management. Dis Colon Rectum 1996;39:1308– 14. 4. Arora G, Mannalithara A, Singh G, Gerson LB, Triadafilopoulos G. Risk of perforation from a colonoscopy in adults: a large population-based study. Gastrointest Endosc 2009;69:654–64.
Surgical emphysema following therapeutic colonoscopy
5. Rabeneck L, Paszat LF, Hilsden RJ, Saskin R, Leddin D, Grunfeld E, et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 2008;135:1899–906. 6. Marwan K, Farmer KC, Varley C, Chapple KS. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema following diagnostic colonoscopy. Ann R Coll Surg Engl 2007; 89:20 –1. 7. Pourmand A, Shokoohi H. Tension pneumothorax, pneumoperitoneum and cervical emphysema following a diagnostic colonoscopy. Case Rep Emerg Med, doi:10.1155/2013/583287.
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8. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984;144:1447–53. 9. Ho HC, Burchell S, Morris P, Yu M. Colon perforation, bilateral pneumothoraces, pneumopericardium, pneumomediastinum, and subcutaneous emphysema complicating endoscopic polypectomy: anatomic and management considerations. Am Surg 1996;62:770–4. 10. Lohsiriwat V. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol 2010;16: 425 – 30.
Case Report
Surgical emphysema following therapeutic colonoscopy Jason Ramsingh*, Ahmad Ali, Ahmed Al-Ani and Gerrit Denys Department of General Surgery, Inverclyde Royal Hospital, Greenock, UK, *Correspondence address. Department of General Surgery, Inverclyde Royal Hospital, Greenock, UK. E-mail: [email protected] Received 22 October 2013; revised 17 November 2013; accepted 18 November 2013
Colonoscopy is an invasive procedure used in the detection of colon cancer, inflammatory bowel disease and investigation of bleeding from the rectum. In addition to diagnostic procedures, colonoscopy also has therapeutic indications such as polypectomy and dilation of strictures. We present a case of a patient who presented with cervical emphysema following a therapeutic colonoscopy. The patient had no abdominal or chest pain, shortness of breath and was managed conservatively. Perforation following colonoscopy is a rare complication; however, it is essential that doctors recognize and are aware of the different presentations and management options for this complication.
INTRODUCTION Colonoscopy is used in the evaluation of diseases affecting the lower gastrointestinal tract. Being an invasive procedure, it is associated with complications that can be managed conservatively or require surgical intervention. In our case report, we discuss a patient who developed surgical emphysema following a therapeutic colonoscopy without any associated abdominal or chest symptoms and was managed conservatively. This case report highlights one of the rare presentations of colonoscopic perforations and provides a feasible management option for clinicians.
CASE REPORT A 60-year-old female presented to our endoscopy suite after being referred by her general practitioner for investigation of bleeding and passage of mucus per rectum. She also complained of tenesmus and reduced appetite but no weight loss. Her past medical history included being diagnosed with ulcerative colitis 26 years ago during her first pregnancy for which she was treated with steroids and has been relatively healthy since then. She had a previous colonoscopy in 2008, following a positive bowel screening. This colonoscopy showed quiescent colitis confirmed by biopsy. During the present colonoscopy, she had biopsies taken from her rectum, sigmoid, descending and ascending colon given the findings of pseudopolyps.
After her procedure she complained of swelling in her neck. This was not accompanied by shortness of breath, chest pain or abdominal pain. On examination, her oxygen saturation was 99% on room air, with normal respiratory and heart rate. Her respiratory examination was normal and her abdomen was soft and non-tender. She had marked crepitus over her clavicles, supraclavicular fossa and most of her neck. Her erect chest X-ray revealed air under both hemidiaphragms and significant pneumomediastinum (Fig. 1). A computed tomography (CT) scan of her chest, abdomen and pelvis was requested. This CT-scan revealed very extensive spreading of surgical emphysema in the retroperitoneum, extending into the mediastinum with small volumes of free intraperitoneal gas (Figs 2 – 4). The patient was admitted and managed conservatively. This consisted of keeping her nil by mouth for 24 h, intravenous fluids and antibiotics. Her cervical emphysema gradually resolved and she was discharged 72 h after presentation without any surgical intervention.
DISCUSSION The rate of perforation following colonoscopy ranges from 0.03 to 0.12% [1, 2]. Perforations can occur from three different mechanisms [3]. First, it can result from mechanical perforation with the colonoscope and is usually recognized at the time of endoscopy. Secondly, it can occur as a result of
Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. # The Author 2013. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by-nc/3.0/), which permits non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected].
Page 2 of 3
J. Ramsingh et al.
Figure 4. CT scan of chest showing an extensive pneumomediastinum. Figure 1. Chest X-ray illustrating pneumoperitonuem, pneumomediastinum and cervical emphysema.
Figure 2. CT scan showing an extensive pneumoretroperitoneum.
Figure 3. CT scan of abdomen showing free intraperitoneal gas compressing the splenic flexure.
overzealous air insufflation or barotrauma. Lastly, it can occur after therapeutic procedures such as polypectomies and biopsies. Various authors have identified significant risk factors for perforation. Arora et al. [4] reported that advanced age, significant comorbidity, obstruction as an indication for colonoscopy and performance of invasive interventions increased
the risk of perforation. Rabeneck et al. [5] also reported that older age, male sex, having a polypectomy and a low volume endoscopic service increased the risk of perforation. Our patient presented after a therapeutic colonoscopy with cervical emphysema as the initial complaint without any abdominal or chest complaints even though her imaging revealed both pneumoperitoneum and pneumomediastinum. Fortunately, she did not exhibit signs of the fourth pneumothorax and did not require a chest drain. This is in stark contrast to previously published case reports where patients developed pneumothoraces requiring chest tube drainage [6, 7]. Maunder et al. [8] has described the path taken by air in the retroperitoneum into the mediastinum. Briefly, air in the retroperitoneum can track upwards entering the mediastinum via the hiatus for the aorta and IVC. The air can then continue along fascial planes into the neck resulting in cervical emphysema. Additionally, air within the peritoneum can enter the mediastinum via the oesophageal hiatus or can pass through openings in the diaphragm to enter the pleural cavity resulting in pneumothorax [9]. Conservative management of perforation following colonoscopy is a safe and acceptable option in patients not exhibiting signs of peritonitis, adequate bowel preparation or silent perforations. Additionally, perforations resulting from therapeutic procedures are usually small and are best managed conservatively [10]. Perforation following colonoscopy is a known but fortunately rare complication. Being aware of the various presentations and management options will improve clinical care.
REFERENCES 1. Cobb WS, Heniford BT, Sigmon LB, Hasan R, Simms C, Kercher KW, et al. Colonoscopic perforations: incidence, management, and outcomes. Am Surg 2004;70:750– 7; discussion 757 –758. 2. Korman LY, Overholt BF, Box T, Winker CK. Perforation during colonoscopy in endoscopic ambulatory surgical centers. Gastrointest Endosc 2003;58:554– 7. 3. Damore LJ, Rantis PC, Vernava AM, Longo WE. Colonscopic perforations. Etiology, diagnosis and management. Dis Colon Rectum 1996;39:1308– 14. 4. Arora G, Mannalithara A, Singh G, Gerson LB, Triadafilopoulos G. Risk of perforation from a colonoscopy in adults: a large population-based study. Gastrointest Endosc 2009;69:654–64.
Surgical emphysema following therapeutic colonoscopy
5. Rabeneck L, Paszat LF, Hilsden RJ, Saskin R, Leddin D, Grunfeld E, et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 2008;135:1899–906. 6. Marwan K, Farmer KC, Varley C, Chapple KS. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema following diagnostic colonoscopy. Ann R Coll Surg Engl 2007; 89:20 –1. 7. Pourmand A, Shokoohi H. Tension pneumothorax, pneumoperitoneum and cervical emphysema following a diagnostic colonoscopy. Case Rep Emerg Med, doi:10.1155/2013/583287.
Page 3 of 3
8. Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984;144:1447–53. 9. Ho HC, Burchell S, Morris P, Yu M. Colon perforation, bilateral pneumothoraces, pneumopericardium, pneumomediastinum, and subcutaneous emphysema complicating endoscopic polypectomy: anatomic and management considerations. Am Surg 1996;62:770–4. 10. Lohsiriwat V. Colonoscopic perforation: Incidence, risk factors, management and outcome. World J Gastroenterol 2010;16: 425 – 30.
