Tension Pneumothorax, Pneumoperitoneum, and Cervical Emphysema following a Diagnostic Colonoscopy

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Abstract

Colonoscopy is currently a widespread procedure used in screening for colorectal cancer. Iatrogenic colonic perforation during colonoscopy is a serious and potentially life-threatening complication that can cause significant morbidity and mortality. “Triple pneumo” (a combination of pneumothorax, pneumomediastinum, and pneumoperitoneum) following colonoscopy is a rare but a serious condition requiring immediate diagnosis and emergent intervention. In majority of these cases a colonic perforation is the initial injury that is followed by pneumothorax and pneumomediastinum through the potential anatomical connection with retroperitoneal and mediastinal spaces. In this rare case report we are presenting a case of “triple pneumo” with no evidence of colonic perforation. This patient developed a simultaneous pneumoperitoneum, pneumomediastinum, and a tension pneumothorax requiring immediate tube thoracostomy. This case may raise the awareness on the likelihood of these serious complications after colonoscopy.

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Most cited references 16

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Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management.

R J Maunder, D J Pierson, L D Hudson (1984)

Subcutaneous emphysema and pneumomediastinum occur frequently in critically ill patients in association with blunt or penetrating trauma, soft-tissue infections, or any condition that creates a gradient between intra-alveolar and perivascular interstitial pressures. A continuum of fascial planes connects cervical soft tissues with the medlastinum and retroperitoneum, permitting aberrant air arising in any one of these areas to spread elsewhere. Diagnosis is made in the appropriate clinical setting by careful physical examination and inspection of the chest roentgenogram. While the presence of air in subcutaneous or mediastinal tissue is not dangerous in itself, prompt recognition of the underlying cause is essential. Certain trauma-related causes may require surgical intervention, but the routine use of chest tubes tracheostomy, or mediastinal drains is not recommended.

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Complications of colonoscopy in an integrated health care delivery system.

Theodore R Levin, Wei Zhao, Carol Conell … (2006)

Information about colonoscopy complications, particularly postpolypectomy bleeding, is limited. To quantify the magnitude and severity of colonoscopy complications. Retrospective cohort. Kaiser Permanente of Northern California. 16, 318 members 40 years of age or older undergoing colonoscopy between January 1994 and July 2002. Electronic records reviewed for serious complications, including hospital admission within 30 days of colonoscopy for colonic perforation, colonic bleeding, diverticulitis, the postpolypectomy syndrome, or other serious illnesses directly related to colonoscopy. 82 serious complications occurred (5.0 per 1000 colonoscopies [95% CI, 4.0 to 6.2 per 1000 colonoscopies]). Serious complications occurred in 0.8 per 1000 colonoscopies without biopsy or polypectomy and in 7.0 per 1000 colonoscopies with biopsy or polypectomy. Perforations occurred in 0.9 per 1000 colonoscopies (CI, 0.5 to 1.5 per 1000 colonoscopies) (0.6 per 1000 without biopsy or polypectomy and 1.1 per 1000 with biopsy or polypectomy). Postbiopsy or postpolypectomy bleeding occurred in 4.8 per 1000 colonoscopies with biopsy (CI, 3.6 to 6.2 per 1000 colonoscopies). Biopsy or polypectomy was associated with an increased risk for any serious complication (rate ratio, 9.2 [CI, 2.9 to 29.0] vs. colonoscopy without biopsy). Ten deaths (1 attributable to colonoscopy) occurred within 30 days of the colonoscopy. 99.3% (16 204) of colonoscopies were nonscreening examinations. The rate of complications may be lower in a primary screening sample. The small number of observed adverse events limited power to detect risk factors for complications. Colonoscopy with biopsy or polypectomy is associated with increased risk for complications. Perforation may also occur during colonoscopies without biopsies.

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Colonoscopic perforations: a review of 30,366 patients.

Eline Luning Prak, C. Rosman, W. Barendregt … (2007)

Although the incidence of perforation after endoscopic procedures of the colon is low, the rising number of procedures could pose relevant health problems. Recognizing risk factors and optimizing treatment may reduce perforation incidence and the probability of (severe) complications. This study aimed to determine perforation frequency and the management of endoscopic colonoscopic perforation. A retrospective review of patient records was performed for all patients with iatrogenic colonic perforations after sigmoido/colonoscopy between 1990 and 2005. The patients' demographic data, endoscopic procedural information, perforation location, therapy, and outcome were recorded. In the 16-year period, 30,366 endoscopic colonic procedures were performed. In total, 35 colonic perforations occured (0.12%). All the patients underwent a laparotomy: for primary repair in 18 cases (56%), for resection with anastomosis in 8 cases (25%), and for resection without anastomosis in 6 cases (19%). In three patients (8.6%), no perforation was found. The postoperative course was uncomplicated in 21 cases (60%) and complicated in 14 cases (40%), including mortality for 3 patients (8.6% resulting from perforations and 0.01% resulting from total endoscopic colon procedures). The relative risk ratio of colonoscopic and sigmoidoscopic procedures for perforations was 4. Therapeutic procedures show a delay in presentation and diagnosis compared with diagnostic procedures. Of the 35 perforations, 26 (74%) occurred in the sigmoid colon. Iatrogenic colonic perforation is a serious but rare complication of colonoscopy. A perforation risk of 0.12% was found. The perforation risk was higher for colonoscopic procedures than for sigmoidoscopic procedures. The sigmoid colon is the area at greatest risk for perforation. Immediate operative management, preferably primary repair and sometimes resection, appears to be a good strategy for most patients.

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Author and article information

Journal

Journal ID (nlm-ta): Case Rep Emerg Med

Journal ID (iso-abbrev): Case Rep Emerg Med

Journal ID (publisher-id): CRIM.EM

Title: Case Reports in Emergency Medicine

Publisher: Hindawi Publishing Corporation

ISSN (Print): 2090-648X

ISSN (Electronic): 2090-6498

Publication date (Print): 2013

Publication date (Electronic): 30 May 2013

Volume: 2013

Electronic Location Identifier: 583287

Affiliations

Department of Emergency Medicine, George Washington University, Washington, DC 20037, USA

Author notes

*Ali Pourmand: pourmand@ 123456gwu.edu

Academic Editors: N. Kikuchi and M. D. Smith

Author information

Ali Pourmand https://orcid.org/0000-0002-8440-8454

Article

DOI: 10.1155/2013/583287

PMC ID: 3683440

PubMed ID: 23819071

SO-VID: ebf49648-df99-48da-80c0-23d0751aabbd

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This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 9 March 2013

Date accepted : 19 May 2013

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Tension Pneumothorax, Pneumoperitoneum, and Cervical Emphysema following a Diagnostic Colonoscopy

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Abstract

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Preventive and Emergency Medicine Insights

Most cited references 16

Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management.

Complications of colonoscopy in an integrated health care delivery system.

Colonoscopic perforations: a review of 30,366 patients.

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