Critical Care: Student/Resident Case Report Poster - Critical Care III |

Colonic Perforation as a Complication of Colonoscopy Presenting With Subcuteneous Emphysema: A Case Presentation FREE TO VIEW

Himani Sharma, MD; Biplab Saha, MD; Kristin Fless, MD; Paul Yodice, MD; Fariborz Rezai, MD; Nirav Mistry, MD; Vagram Ovnanian, MD
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Saint Barnabas Medical Center, West Orange, NJ

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):411A. doi:10.1016/j.chest.2016.08.424
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care III

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Iatrogenic perforation is the most feared complication of colonoscopy and often culminates in peritonitis, septic shock with a mortality rate up to 25 %. Although most colonic perforations are intra peritoneal, extra peritoneal perforation have also been reported. However, a combination of both is extremely rare and only 7 such cases exist in the literature. While free air under the diaphragm suggests intraperitoneal perforation, extra peritoneal perforation is evidenced by pneumoretroperitonium, pneumomediastinum, pneumopericardium, pneumothorax and often subcutaneous emphysema.

CASE PRESENTATION: A 41-year-old female with a 1 year history of ulcerative colitis (UC) treated with vedolizumab and prednisone was admitted to critical care unit with fever, watery diarrhea and lower abdominal pain. Her other history included recurrent C difficile colitis, for which she underwent fecal microbiota transfer 2 weeks prior to admission. Vital signs showed pulse 127 beats, BP 60/35 mm Hg, temperature 101 F and respiratory rate 24. Physical examination revealed diffuse abdominal tenderness but no rebound. Laboratory evaluation was significant for leukocytosis16.8 with a lactic acid of 4.7. Urinalysis was positive and blood culture subsequently grew E. coli. CT scan demonstrated diffuse colitis, transverse colon diameter of 2.4 cm and right pyelonephritis. She was treated for septic shock and exacerbation of UC. Her condition improved over the next few days but the lactic acidosis persisted. Colonoscopy on day 7 revealed severe colitis and ulcers in the sigmoid and descending colon and mild colitis in the distal transverse colon. Biopsies were obtained from the sigmoid and descending colon. The following day, she was noted to have subcutaneous emphysema of the chest wall. CT chest, abdomen and pelvis revealed large pneumoperitoneum, pneumoretroperitonium, pneumomediastinum and pneumopericardium with air tracking all the way up into the neck. Patient remained clinically asymptomatic. She had an exploratory laparotomy and was found to have transverse colon perforation and underwent subtotal colectomy with end ileostomy.

DISCUSSION: Abdominal pain is the most common symptom following colonic perforation but use of immunosuppressive medication can result in an atypical presentation. Combined intra and extraperitoneal perforation is extremely rare and out of 7 reported cases, interestingly UC was present in 4 of them. Patients typically get acutely sick but they can remain relatively asymptomatic especially if on immunosuppressive medications.

CONCLUSIONS: Physicians should be cognizant of the possibility of retroperitoneal perforation with atypical presentation after colonoscopy especially in patient with UC. Abdominal processes may rarely present with subcutaneous emphysema and pneumomediastinum. Early identification and intervention could be life saving.

Reference #1: Complications of colonoscopy, GASTROINTESTINAL ENDOSCOPY Volume 74, No. 4 : 2011

DISCLOSURE: The following authors have nothing to disclose: Himani Sharma, Biplab Saha, Kristin Fless, Paul Yodice, Fariborz Rezai, Nirav Mistry, Vagram Ovnanian

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