Subcutaneous emphysema of gastrointestinal origin: report of four cases

Mediastinal, retroperitoneal, and subcutaneous emphysema due to sigmoid colon penetration: A case report and literature review

INTRODUCTION

Mediastinal and subcutaneous emphysema usually result from spontaneous rupture of the alveolar wall. We present an extremely rare case of massive mediastinal, retroperitoneal, and subcutaneous emphysema due to the penetration of the colon into the mesentery.

PRESENTATION OF CASE

A 57-year-old man presented to our institution with a history of chest pain. The patient's medical history included malignant rheumatoid arthritis during the use of steroids and an immunosuppressive agent. The patient had no signs of peritoneal irritation or abdominal pain. A chest radiography revealed subcutaneous emphysema of the neck, mediastinal emphysema, as well as subdiaphragmatic free air. Computed tomography showed extensive retroperitoneal, mediastinal, and mesenteric emphysema of the sigmoid colon without pneumothorax. Diagnostic laparoscopy was performed and revealed perforation into the sigmoid mesentery. Segmental resection of the sigmoid colon and end-colostomy were performed. The diverticulum was communicating with the outside of the mesentery via the mesentery. The mediastinal emphysema disappeared a few days after the surgery.

DISCUSSION

Colonic perforation generally results in free perforation. Colonic gas may spread via various anatomical pathways when perforation of the colon occurs in the retroperitoneum; thus, diverse atypical clinical symptoms may be present. Signs of peritoneal irritation can be hidden in cases of retroperitoneal colonic perforation. The atypical manifestation of a retroperitoneal colonic perforation can cause difficulties in making a diagnosis.

CONCLUSIONS

Massive mediastinal and retroperitoneum emphysema are rare signs of colonic perforation. Emergency laparotomy should be considered in colonic penetration of the diverticulitis where the emphysema expands to the mediastinum extensively.

"Flatus profuse present in the muscles": subcutaneous emphysema of the lower abdominal wall and thighs, described in 1593 by fabricius hildanus

BACKGROUND

Between 1598 and 1641, 600 medical and surgical observations made by the famous German surgeon Guilhelmius Fabricius Hildanus (1560-1634) were published in his Observationum et curationum chirurgicarum centuriae I-VI.

METHODS

Review of the extant document for evidence of infection-related cases.

RESULTS

One of the case reports, published as Observatio LXX in the fifth Centuria, bears the title (in translation) Of flatus, profuse present in the muscles. This case report probably is the earliest accurate description of subcutaneous emphysema of the lower abdomen and thighs secondary to a retroperitoneal abscess.

CONCLUSION

The presence of gas in the superficial tissues of the abdominal wall or thighs is a rare feature and can be a late sign of an otherwise-obscure intra-abdominal abscess with gas-producing bacteria. Fabricius Hildanus almost certainly was the first to document this rare feature in 1593, and judged it important enough to describe in his Centuriae.