Pneumomediastinum in inflammatory bowel disease

Ulcerative colitis complicating pneumomediastinum, subcutaneous emphysema and pneumothorax

A 17-year-old man with ulcerative colitis (UC) presented to our hospital with neck pain and fever after vomiting. On examination, a snowflake sensation was noted in the neck. A chest radiograph showed extensive subcutaneous emphysema in the chest. CT scans showed extensive subcutaneous emphysema in the neck, shoulders and axilla, as well as pneumomediastinum and pneumothorax. A diagnosis of pneumomediastinum with exacerbation of UC was made, and he was fasted and treated with antibiotics. Intensive granulocyte and monocyte adsorption apheresis (GMA) was started for exacerbation of UC. His symptoms and the radiological findings of pneumomediastinum improved. He remained in remission on azathioprine. UC is a chronic inflammatory bowel disease (IBD) associated with extraintestinal manifestations (EIM). Very few cases have been complicated by pneumomediastinum. The increase in alveolar pressure due to vomiting and systemic inflammation-related pleural or esophageal damage may cause pneumomediastinum in this case. Prevention of progression to mediastinitis and treatment of exacerbated UC are contradictory. GMA was successful because it was not an immunosuppressive therapy. Our case highlights that rare EIM may complicate exacerbation of UC.

Spontaneous pneumomediastinum: A comprehensive review of diagnosis and management

Pneumomediastinum is a rare condition defined by the presence of air in the mediastinum. In the absence of traumatic injury, iatrogenic injury, or clear etiology, it is called spontaneous pneumomediastinum (SPM). Spontaneous pneumomediastinum most commonly occurs in younger individuals and has a self-limiting course with a good outcome. The purpose of the present manuscript is to systematically review the existing literature on SPM evaluation and management for updated clinical understanding of this condition. A literature search was conducted of publications about SPM on MEDLINE/PubMed and Google Scholar by identifying all the articles with key search terms "pneumomediastinum" and "spontaneous pneumomediastinum". Inclusion criteria were case series published in English between 1980 and 2023. In total, 24 case series were selected and reviewed to determine presenting symptoms, clinical signs and predisposing factors associated with spontaneous pneumomediastinum. Most patients were male; the average age at diagnosis was 26.3 years. The most common presenting symptoms were chest pain and dyspnea. The most common exam finding was subcutaneous emphysema, in 35.4% of patients. Only 5.9% had the classic Hamman's sign. Risk factors include history of asthma, history of smoking, and recent physical activity. This manuscript presents an extensive review of relevant literature highlighting the diagnosis and essential management of spontaneous pneumomediastinum.

A rare complication of acute severe ulcerative colitis

A 21-year-old female with ulcerative colitis presented with abdominal pain and bloody diarrhea. Laboratory studies revealed markedly elevated C-reactive protein and thrombocytosis. Flexible sigmoidoscopy revealed severe endoscopic activity with ulceration and spontaneous bleeding along rectum and sigmoid colon. Ulcerative colitis had been diagnosed 3 years before, presenting as severe and extensive disease (pancolitis). She had previously failed therapy with infliximab and vedolizumab and had recently started induction therapy with golimumab. She responded well to intravenous corticosteroids but, when switched to oral corticosteroids, there was symptomatic recurrence. Intravenous corticosteroids were re-started and she was evaluated for surgery. At this time, she developed new-onset tachycardia. Electrocardiogram revealed sinus tachycardia with heart rate of approximately 120 bpm. Because tachycardia could result from worsening colitis with potential serious complications, abdominal computerized tomography scan was performed and demonstrated mild lumen dilation and wall thickening consistent with acute colitis without evidence of pneumoperitoneum or toxic megacolon. Surprisingly, thoracic planes revealed the presence of free air dissecting mediastinal space (Figure 1). What is your diagnosis?