Anatomical and Radiological Considerations When Colonic Perforation Leads to Subcutaneous Emphysema, Pneumothoraces, Pneumomediastinum, and Mediastinal Shift

Abstract

While colonoscopy is generally regarded as a safe procedure, colonic perforation can occur and the risk of this is higher when interventional procedures are undertaken. The presentation may be acute or delayed depending on the extent of the perforation. Extracolonic gas following colonic perforation can migrate to several body compartments that are embryologically related and it has previously been reported in the thorax, mediastinum, neck, scrotum, and lower limbs. This review discusses in detail the anatomical pathways that led to a rare case of widespread subcutaneous emphysema, bilateral pneumothoraces, pneumomediastinum, and mediastinal shift from colonic perforation during a diagnostic colonoscopy. This is further supported by a description of the radiological images.

Pneumomediastinum, Pneumoretroperitoneum, Pneumoperitoneum and Subcutaneous Emphysema Secondary to a Penetrating Anal Injury

“…Simultaneous occurrence of pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum and subcutaneous emphysema is rare. The most commonly reported mechanisms are barotrauma, thermal injury and instrument puncture caused by colonoscopy [ 1 , 2 , 3 ]. Depending on the site of perforation, intraluminal air may escape into the peritoneal or retroperitoneal space [ 1 , 2 ].…”

“…The most commonly reported mechanisms are barotrauma, thermal injury and instrument puncture caused by colonoscopy [ 1 , 2 , 3 ]. Depending on the site of perforation, intraluminal air may escape into the peritoneal or retroperitoneal space [ 1 , 2 ]. The ectopic air may travel into different body compartments through distinct anatomical fascial planes [ 1 ].…”

“…Depending on the site of perforation, intraluminal air may escape into the peritoneal or retroperitoneal space [ 1 , 2 ]. The ectopic air may travel into different body compartments through distinct anatomical fascial planes [ 1 ]. Retroperitoneal air may pass into the mediastinum through esophageal or aortic hiatus of the diaphragm [ 1 , 2 , 3 , 4 ].…”

“…The ectopic air may travel into different body compartments through distinct anatomical fascial planes [ 1 ]. Retroperitoneal air may pass into the mediastinum through esophageal or aortic hiatus of the diaphragm [ 1 , 2 , 3 , 4 ]. Subcutaneous emphysema may occur when air travels along the mesentery to abdominal wall and then spreads to the chest wall [ 1 ].…”

“…Retroperitoneal air may pass into the mediastinum through esophageal or aortic hiatus of the diaphragm [ 1 , 2 , 3 , 4 ]. Subcutaneous emphysema may occur when air travels along the mesentery to abdominal wall and then spreads to the chest wall [ 1 ]. In rare cases, pneumothorax can occur if the mediastinal parietal pleural ruptures [ 2 ].…”