ABSTRACT

Colonoscopy is a commonly used procedure for diagnosis and treatment. Perforation during colonoscopy is a rare complication. We aimed to present a case which is extremely rare with pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema occurred after perforation during colonoscopy.

Introduction

Colonoscopy is a method widely used for diagnosis and treatment. Colonoscopic perforation is rarely seen with an incidence rate of nearly 0.15-0.19%.^1,2 Subdiaphragmatic air, intraperitoneal air, pneumoretroperitoneum, pneumothorax and subcutaneous emphysema may be seen following colonic perforation. Herein, clinical presentation, diagnosis and treatment of a case with retroperitoneal air, pneumomediastinum and subcutaneous emphysema after colonoscopy have been reported.

Discussion

Colonoscopy is widely used as a diagnostic and therapeutic tool in the colorectal diseases. There may be many complications associated with colonoscopy. Bleeding is the most prevalent complication, where perforation is less common. It has been suggested that many different mechanisms including pneumatic, mechanical and therapeutic mechanisms cause perforation. The incidence of perforation increases in the patients who have colonic mass, diverticula, inflammatory bowel diseases or history of previous abdominal surgery.³ In the present case, we considered perforation due to therapeutic procedure.

In case of perforation, extracolonic air may pass through the retroperitoneal tissue layers and cause subcutaneous emphysema in the neck, axilla, anterior chest wall and scrotum. Moreover, it may lead to pneumothorax, pneumopericardium, pneumomediastinum and pneumatosis cystoides intestinalis.^4,5,6 In the present case, PARSP revealed no subdiaphragmatic free air but limited intraperitoneal and retroperitoneal air was detected on thoracic and abdominal CT. In addition, pneumomediastinum and subcutaneous emphysema in the neck and anterior chest wall were observed.

Approaching to perforation after colonoscopy includes conservative, endoscopic and surgical approaches. Conservative approach consists of bed rest, discontinuation of oral intake, broad-spectrum antibiotherapy, and close monitoring via radiological methods. Patients that require conservative therapy account for a small proportion of overall perforation cases, and the symptoms of the cases regress in 24 hours. Such patients generally have retroperitoneal perforation and/or perforation after therapeutic procedure.³ In the present case, surgical intervention was not considered in the first plan as her clinical status was stable, she had no sign of sepsis or peritonitis, and cleansing of her bowel has been performed precisely. The patient received conservative treatment because her clinical, laboratory and radiological findings showed no significant change.

In conclusion, colonoscopic perforation can be seen even though it is uncommon. In addition, intraperitoneal air, pneumomediastinum, pneumoretroperitoneum and subcutaneous emphysema as well may accompany perforation. Conservative approach should be kept in mind as a therapeutic option in the patients with no sign of peritoneal irritation.