Four days after a routine colonosco...

Four days after a routine colonoscopy for follow-up of Crohn's disease, a 40-year-old woman existinged to the emergency department with morose abdominal pain, nausea, and a "noisy" neck Right after the step she had developed abdominal pain and nausea that persisted after arriving abode She repeatedly vomited, and her symptoms advanceed to include fever and chills, and gradual swelling of the neck and face. Her physical examination forward arrival in the emergency department was remarkable for diffuse abdominal tendernes and a crunching healthy audible in the neck region that coincided with her pulsation Her chest and abdominal radiographs are shown in Figures 1 from one side 3.

Question

Based forward this presentation and the woman's history, physical examination, and radiographs, which single of the following statements is correct?

[ ] A. The first brunt of pain soon after the act is unusual for colonic perforation.

[ ] B A lateral decubitus radiograph is more sensitive than an upright abdominal film for the nearness of free air.

[ ] C A comput tomography scan of the abdomen cannot reliably discover pneumoperitoneum.

[ ] D The neighborhood of pneumomediastinum in a case of colon perforation is an indication for early surgery

[ ] E The patient's history of Crohn's disease is a risk factor for perforation during colonoscopy.

Discussion

The answer is E: The neighborhood of intestinal pathology, such as diverticulitis, inflammatory bowel disease, colonic stricture, or previous abdominal surgery predisposes the colon to perforation during endoscopy. The incidence of perforation has been reported to range from 01 percent for flexible sigmoidoscopy, to 016 percent for diagnostic colonoscopies, and 044 percent for colonoscopy with lesion biopsy or resection. (1) greatest in quantity perforations occur in the rectosigmoid junction or the sigmoid colon

Pneumomediastinum (Figure 1) may present itself because of forceful vomiting with following esophageal rupture (Boerhaave's syndrome), moreover it also may be caused according to perforation of the colon with spread of intraperitoneal air from one side the peridiaphragmatic defect into the thorax. Colonic perforation can lead to air accumulation in a variety of places including subcutaneous emphysema, pneumatosis coli, pneumoscrotum pneumopericardium, and pneumothorax. (1)

In patients with colon perforation, the clinical presentation is quite variable. The class of complications depends on the size, site, and mechanism of perforation, as well as the underlying colonic pathology, measure of peritoneal contamination, and the condition of the patient. (2) The in the greatest degree common symptom of perforation is abdominal pain. The attack of pain usually occurs during or shortly after completion of the step but it may be delayed or on the same level nonexistent in some instances. In the mostly severe cases of perforation, spillage of bowel make easys leads to peritonitis, sepsis, and circulatory collapse. Physicians should be alert for seemingly unrelated presenting complaints, in the same state [i]or[/i] condition as shortness of breath or chest pain that may glance at pneumomediastinum. Subcutaneous emphysema can be diagnosed by way of the presence of crunching hardys coinciding with the heart rate, crepitus when palpating the overlying skin, or swelling of the face and neck

Colon perforation with intraperitoneal air is usually easily ascertained on an upright chest film. In this case, a sickle-shaped collection of air is seen forward the right side between the diaphragm and the dome of the liver (Figure 1 black arrow). It is best if the patient can stay in the upright position for five to 10 minutes before obtaining the radiograph. In this position, it is possible to descry as little as 1 to 2 mL of released air. For those patients who cannot maintain an construct position, a left lateral decubitus view of the abdomen may present to view the free air collecting between the lateral margin of the liver and the abdominal wall.

Figure 2 demonstrates a retroperitoneal perforation with air outlining the liver cutting side right kidney (open arrow and short, black arrow), and the psoas muscle cutting side (long arrow). Pneumomediastinum can be diagnosed at demonstration of a thin, vertically oriented line of radiolucency, usually best seen along the left cardiac border and aortic knob (Figure 1 white arrow). A lateral chest radiograph may be particularly useful in detecting pneumopericardium, demonstrating the nearness of retrosternal air (Figure 3)

Occasionally, plain radiographs may be normal in patients with colonic perforation and pneumoperitoneum. In of that kind patients, air may be readily visualized on computed tomography (CT). A CT scan is extremely sensitive and is superior to upright chest radiography for detection of pneumoperitoneum. (2)

The management of colon perforation after colonoscopy is controversial. There are no randomized prospective studies available comparing expectant management to early surgical intervention. Typically, stable patients are managed conservatively with stop clinical monitoring. (3,4) The mien of subcutaneous emphysema, pneumoretroperitoneum, or pneumomediastinum after colonic perforation is not an absolute indication for surgery (45) Bowel security intravenous fluids, and intravenous antibiotics to shield enteric gram-negative and anaerobic organisms, with stop up observation for evidence of clinical deterioration are typical measures for conservative management.