Subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum, and pneumoscrotum: unusual complications of acute perforated diverticulitis

Pneumothorax, Pneumomediastinum, and Cervical and Facial Massive Emphysema Secondary to Colonoscopy: A Rare Complication of Colonoscopy

Background

Colonoscopy is a resource used for the diagnosis, treatment, and monitoring of benign and malignant colorectal pathologies. The incidence of perforation is 0.03%-0.65% in diagnostic colonoscopy; however, the incidence can be up to 10 times higher in therapeutic interventions, such as polypectomies, increasing the risk of complications up to 0.07-2.1%. Materials and methods. Case report of a 71-year-old female who presents a rare complication due to a perforation in the sigmoid which developed pneumoperitoneum, pneumomediastinum, pneumothorax, and massive subcutaneous emphysema as a complication of a diagnostic colonoscopy where a biopsy of a friable lesion was performed.

Results

A 71-year-old female that went to the emergency room due to acute generalized abdominal colic spasm pain with a duration of 7 hours, associated with significant abdominal distension, malaise, diaphoresis, progressive dyspnea, and massive subcutaneous emphysema that developed after performing panendoscopy and colonoscopy for diverticulosis follow-up. An abdominal CT scan with double contrast was performed, reporting suggestive data of hollow viscus perforation, pneumoperitoneum, pneumomediastinum, pneumothorax, and massive subcutaneous emphysema in the thorax, neck, and skull base. She underwent an exploratory laparotomy finding a perforation in the sigmoid for which sigmoidectomy was performed, and for the pneumothorax and pneumomediastinum, endopleural tubes were placed in both hemithoraxes. The massive subcutaneous emphysema subsided with observation and oxygen.

Conclusion

A rare complication of the use of colonoscopy as a diagnostic and therapeutic method is presented. The purpose of presenting this case is for the doctor who performs these interventions to suspect this complication in a timely manner, not delaying the diagnosis and carrying out an urgent therapeutic approach as in this case with exploratory laparotomy, finding the perforation site and carrying out the corresponding surgical management. We demonstrated that massive subcutaneous emphysema can be managed with observation if there is no other alarm data evident that required another surgical approach.

Complicated retroperitoneal diverticulitis presenting with abscess and acute limb ischemia

This case highlights a rare presentation of diverticulitis of the sigmoid colon with perforation into the retroperitoneum complicated by abscess, vertebral osteomyelitis and acute lower extremity ischemia. A late 40-year-old man presented to an emergency department with acute ischemia of his left lower extremity. He was tachycardic with a leucocytosis, an unremarkable abdominal exam and a pulseless, insensate and paralysed left lower extremity. Imaging revealed sigmoid thickening, an abscess adjacent to iliac vasculature and occlusion of the left popliteal artery. The abscess came in contact with prior spine anterior lumbar interbody fusion (ALIF) hardware at L5-S1 vertebrae. The patient was taken urgently to the operating room for embolectomy, thrombectomy and fasciotomy. He was started on antibiotics and later underwent operative drainage with debridement for osteomyelitis. Non-operative management of the complicated diverticulitis failed, necessitating open sigmoidectomy with colostomy. 1 year later, he was symptom-free and the colostomy was reversed.

The Development of Extensive Subcutaneous Emphysema Following Robotic Total Abdominal Colectomy Due to Lynch Syndrome: A Case Report

Subcutaneous emphysema, the presence of air in the subcutaneous layer of the skin, is a possible result of surgical, infectious, or spontaneous etiologies. Although usually self-limiting, the development of subcutaneous emphysema in the perioperative period has been associated with delayed extubation and the development of complications such as pneumomediastinum, pneumoperitoneum, and pneumothorax and can worsen clinical outcomes in these patients. Here, we report the case of a 57-year-old male patient who presented to the operating room (OR) for a robotic total colectomy due to Lynch syndrome. The procedure was complicated by the development of diffuse, severe subcutaneous emphysema, which was recognized by palpable crepitus and obscuration of anatomical landmarks during an attempted transversus abdominis plane (TAP) block for pain control prior to patient extubation. The decision was made to leave the patient intubated and managed postoperatively in the ICU, where radiographic and computerized tomography (CT) scans confirmed the severity of subcutaneous emphysema. Hemodynamic and respiratory status were managed in the ICU and on postoperative day 3 the patient passed an endotracheal cuff leak test and was extubated. The patient was transferred to a surgical step-down on postoperative day 7 and following the resolution of ileus and acute kidney injury (AKI), he was discharged from the hospital on postoperative day 17.

Retroperitoneal and Mediastinal Emphysema after Sigmoid Colon Resection

Retroperitoneal and mediastinal emphysema after colon resection is extremely rare, especially in the absence of anastomotic leakage. The feasibility and safety of conservative treatment for this complication are unknown. We report a patient who underwent open sigmoid colon resection for colon cancer and developed retroperitoneal and mediastinal emphysema that was not caused by anastomotic leakage. Retroperitoneal and mediastinal emphysema occurred as a result of diverticular perforation. We were able to treat this patient successfully with conservative management.

Extensive Subcutaneous Emphysema Associated With Pneumothorax, Pneumomediastinum, and Pneumoperitoneum: A Case Report

Subcutaneous emphysema (SE ) is a phenomenon in which air occupies structures under the skin and soft tissues. Common sites for SE include the neck and chest wall, which can extend to other body regions. In this case report, we describe the development of extensive SE, pneumothorax, pneumomediastinum, and pneumoperitoneum in an elderly female following blunt trauma to her right flank. The etiology of SE is broad and includes blunt and penetrating traumas; surgical, infectious, spontaneous causes; or any condition that yields a gradient between intra-alveolar and perivascular interstitial pressures. The incidence of SE has been reported to be 1.4%, while that of spontaneous pneumothorax has been reported to be 0.8% in patients receiving a percutaneous tracheostomy. Conversely, the occurrence of SE, pneumothorax, pneumomediastinum, and pneumoperitoneum in the same patient is rare. The most common signs and symptoms of SE are neck swelling and chest pain. Involvement of the deeper tissues of the thoracic outlet, chest, and abdominal wall often manifests in severe life-threatening conditions. SE can be diagnosed by detecting edema and crepitus of the scalp, neck, thorax, abdomen, and other body regions. Radiograph imaging can confirm the presence of soft-tissue air entry. Extensive SE in the setting of pneumothorax is an unusual entity for which there is, as of now, no consensus in management. Methods of treatment include supportive care, placement of blow holes for evacuation of soft-tissue emphysema, and bilateral infraclavicular incisions. SE is a rare complication that can arise from several etiologies. At the same time, various methods for managing this phenomenon have been mentioned with varying successful outcomes.

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.

Clinical signs of retroperitoneal abscess from colonic perforation: Two case reports and literature review

RATIONALE

Retroperitoneal colonic perforation is a rare cause of retroperitoneal abscess. It presents, more frequently in frail elderly patients, with heterogeneous signs and symptoms which hamper the clinical diagnosis. Subcutaneous emphysema with pneumomediastinum and iliopsoas muscle abscess are unusual signs. Colonic retroperitoneal perforation may be consequent to diverticulitis or locally advanced colon cancer. Due to the anatomy of the retroperitoneal space and different physiopathology, diverticular perforation may present with air and pus collection; on the other hand perforated colon cancer may cause groin mass and psoas abscess. We reported 2 cases of colonic retroperitoneal perforation from diverticulitis and locally advanced colon cancer, respectively. Aim of this report is to improve differential diagnosis based on clinical signs.

PATIENTS' CONCERNS

A 71-year-old man presented with pain in his left side, fatigue, fever, nausea, massive subcutaneous emphysema of the neck, and Blumberg sign in the left iliac fossa. A 67-year-old man presented with abdominal pain, sub-occlusion, left groin mass, left groin, and lower limb pain during walking, negative Blumberg sign.

DIAGNOSIS

In the first patient the computerized tomography revealed pneumoperitoneum, gas in the mesosigma, pneumomediastinum, wall thickening of the descending colon, and retroperitoneal collection from diverticular perforation. In the second patient abdominal CT scan found thickening of the sigmoid colon adherent to the iliopsoas and fluid collection.

INTERVENTIONS

In the first patient, a left hemicolectomy extending to the transverse colon, followed by a toilette and debridement of the retroperitoneum were performed. In the second patient, tumor of descending colon perforated in the retroperitoneum with iliopsoas abscess was treated with left hemicolectomy and a drainage of the abscess.

OUTCOMES

The first patient underwent right colectomy with ileostomy in the 7 postoperative day for large bowel necrosis. He died of sepsis 2 days after. The second patient had regular postoperative and he is still alive.

LESSONS

The spread of retroperitoneal abscess in complicated colonic diverticulitis is different from that in advanced colonic cancer. The former can present with a subcutaneous emphysema, the latter with a groin mass. Hence a thorough clinical examination and radiological studies are needed to diagnose these conditions.

Diffuse Subcutaneous Emphysema and Pneumomediastinum Secondary to a Minor Blunt Chest Trauma

Full medical evaluation is paramount for all trauma patients. Minor traumas are often overlooked, as they are thought to bear low injury potential. In this case report, we describe the case of a 48-year-old man presenting to our Emergency Department with mild to moderate right-sided shoulder and scapular pain following a fall from his own height ten days previously. Clinical and paraclinical investigations (CT) revealed diffuse right shoulder pain, with crepitations on palpation of the neck, right shoulder, and right lateral chest wall. Computed tomography (CT) demonstrated right-sided costal fractures (ribs 7 to 9), with diffuse subcutaneous emphysema and pneumomediastinum due to laceration of the visceral and parietal pleura and the adjacent lung parenchyma. In addition, a small ipsilateral pneumothorax was found. Surprisingly, the clinical status was only minimally affected by mild to moderate pain and minor functional impairment.

Pneumoscrotum With Extensive Penile and Abdominal Subcutaneous Emphysema: A Case Report of Uncertain Etiology

Pneumoscrotum and subcutaneous emphysema make for impressive findings on examination and imaging. With ranging etiologies, thorough investigation into the source is essential to rule out potentially life threatening situations. We present a 31-year-old man with pneumoscrotum and extensive subcutaneous emphysema of his penis, abdomen, and perineum. History and physical exam didn't reveal a clear cause and he subsequently underwent surgical exploration showing no soft tissue infection. On post-operative day 1, he remained clinically stable and was discharged. Despite the usual benign nature of pneumoscrotum, full assessment is necessary to identify possible underlying conditions of significant morbidity and mortality.

Diverticulitis: a comprehensive review with usual and unusual complications

Abstract

Diverticulitis is characterized by inflammation of the outpouchings of the bowel wall. Imaging findings of diverticulitis include edematous thickening of the bowel wall with inflammatory changes within the adjacent mesenteric fat. Uncomplicated diverticulitis can be treated conservatively; however, complicated diverticulitis may not be responsive to medical treatment and life-threatening conditions may occur. In this review, we aimed to illustrate the ultrasonography (US) and computed tomography (CT) features of diverticulitis and its complications including perforation, phlegmon, abscess, ascending septic thrombophlebitis (phylephlebitis), bleeding, intestinal obstruction, and fistula.

Teaching Points

• Complications of diverticulitis may be highly variable.

• It may be difficult to diagnose diverticulitis as underlying cause of severe complications.

• MDCT is essential for the primary diagnosis of the acute diverticulitis and its complications.

Subcutaneous cervical emphysema and pneumomediastinum due to a diastatic rupture of the cecum

Pneumomediastinum usually occurs after esophageal or chest trauma. Subcutaneous cervical emphysema as a presentation of non-traumatic colonic perforation following colorectal cancer or diverticulitis, is very rare. We report a case of a patient with rectal cancer who developed a diastatic cecum retroperitoneal perforation with a secondary pneumomediastinum and cervical emphysema. The patient was in treatment with a neoadjuvant chemo-radiotherapy for a low rectal cancer. Treatment consisted in an emergency right hemi-colectomy with ileostomy and performance of distal colonic fistula. The Authors discuss the occurrence of pneumomediastinum and cervical emphysema complicating rectal cancer, pointing out ethiopathogenesis, clinical presentation, diagnosis and treatment. The importance of performing a diverting colostomy when neoadjuvant chemotherapy is scheduled in patients with stenotic rectal cancer, although not clinically occluded.

Extensive Subcutaneous Emphysema as a Presentation of Ischemic Colitis

Introduction. Subcutaneous emphysema is usually benign and self-limited; however, it may be associated with a life-threating situation. Case Report. An elderly woman with progressive malaise with extensive subcutaneous emphysema (cervical to abdominal wall) was observed at the emergency department. Colonic perforation was diagnosed and the patient underwent surgery. Intraoperatively, necrosis and perforation of the sigmoid colon into the retroperitoneum were found and a Hartmann procedure was performed. Conclusion. Cervical and thoracic subcutaneous emphysema may be the first sign of intra-abdominal lesion.

Pneumopericardium, pneumomediastinum, pneumothorax and pneumoretroperitoneum complicating pulmonary metastatic carcinoma in a cat

This report describes a case of severe spontaneous tension pneumopericardium with concurrent pneumomediastinum, pneumothorax and retropneumoperitoneum in a cat presenting with dyspnoea and signs of cardiac tamponade secondary to metastatic pulmonary carcinoma. Spontaneous pneumopericardium is an extremely uncommon condition consisting of pericardial gas in the absence of iatrogenic/traumatic causes. In humans, it has been described secondary to pneumonia or lung abscess and very rarely secondary to pulmonary neoplasia.