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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 106-108

Colonic perforation revealed by massive subcutaneous emphysema


1 Medico-Surgical Intensive Care Department, Versailles Hospital, Le Chesnay Cedex, Paris, France
2 INSERM U970, Paris Cardiovascular Research Center, European Hospital Georges Pompidou, Paris, France

Date of Submission14-Mar-2020
Date of Acceptance01-Jun-2020
Date of Web Publication29-Jun-2021

Correspondence Address:
Dr. Sylvain Diop
Medico-Surgical Intensive Care Department, Versailles Hospital, 177 Rue de Versailles, 78150 Le Chesnay Cedex,
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCIIS.IJCIIS_24_20

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   Abstract 


We present the case of an 82-year-old woman admitted in the intensive care unit with a septic shock caused by a liver abscess. She underwent an emergency laparotomy for abscess drainage and microbiological sampling. In the early postoperative period, she developed a massive subcutaneous emphysema (SE) extending from the abdomen to the head, without obvious cause. A surgical complication was suspected; thus, the patient underwent a second laparotomy which revealed a perforated peritonitis. SE is a rare presentation of perforated peritonitis, which should be known by critical care physicians in order to avoid a misdiagnosis of this life-threatening pathology.

Keywords: Multiple organ failure, peritonitis, septic shock, subcutaneous emphysema


How to cite this article:
Diop S, Giabicani M, Legriel1 S. Colonic perforation revealed by massive subcutaneous emphysema. Int J Crit Illn Inj Sci 2021;11:106-8

How to cite this URL:
Diop S, Giabicani M, Legriel1 S. Colonic perforation revealed by massive subcutaneous emphysema. Int J Crit Illn Inj Sci [serial online] 2021 [cited 2022 Dec 9];11:106-8. Available from: https://www.ijciis.org/text.asp?2021/11/2/106/319779




   Introduction Top


Subcutaneous emphysema (SE) is defined as the presence of extra-alveolar air in soft tissue, diffusing through fascial planes.[1] The main causes of SE are dominated by soft-tissue infection, traumatic injuries with disruption of mucosal or cutaneous barriers, or alveolar rupture in case of brutal increase of the gradient pressure between alveoli and the surrounding interstitial tissue.[1] In rare occasions, SE may occur after extraperitoneal colonic perforation following colonoscopy.[2],[3] However, this rare presentation of colonic perforation, particularly without suggestive medical history, may delayed the diagnosis of this life-threatening condition. Informed consent from the patient's family was obtained before writing this case report.


   Case Report Top


An 82-year-old woman, with a body weight of 57 kg, with a medical history of treated arterial hypertension, was admitted to our intensive care unit (ICU) with the diagnosis of septic shock. First physical examination found a heart rate at 124/min and blood pressure at 80/45 mmHg without response after 1-L crystalloid fluid expansion. The patient had a polypnea at 28 cycles/min without other respiratory distress sign. The abdomen was tense and painful to the palpation. First laboratory blood test showed a hyperlactatemia-related metabolic acidosis with a pH at 7.21, a PCO2 at 24 mmHg, a bicarbonate level at 14 mmoL/L, and a lactate level at 9 mmoL/L. Abdomen and pelvis computed tomography (CT) scan with injection of contrast material showed a voluminous liver abscess [Figure 1, Panel A], consistent with the diagnosis of liver abscess-associated septic shock. Rapidly, the patient developed respiratory and hemodynamic failure with the need of mechanical ventilation, and continuous norepinephrine infusion up to 8 mg/h. An empiric broad-spectrum antimicrobial therapy consisting of piperacillin/tazobactam 4 g fourth a day and one injection of 8 mg/k of gentamicin (480 mg) was administrated for up to 3 weeks. The patient underwent an emergency laparotomy surgery for microbiological sampling and drainage of the liver abscess. In the early postoperative course, the patient demonstrated crepitation of the thoracic and cervical region consistent with the diagnosis of SE. A second CT scan confirmed the presence of massive SE extending from the abdomen to the head associated with a pneumoperitoneum [Figure 1, Panels B to D]. Of note, SE was found neither during the first physical examination at ICU admission nor on the first CT scan. There were no arguments, for upper airway injuries or pneumothorax. Because of the pneumoperitoneum, an early surgical complication was suspected; thus, the patient underwent a second emergency laparotomy which revealed a perforated lesion of the transverse colon. Five centimeters of colon was removed, and a colostomy was carried out. Unfortunately, despite surgery, the patient passed away few days later due to multiorgan failure.
Figure 1: The liver abscess and the massive subcutaneous emphysema. Panel A. Transversal section from a computed tomography scan of the abdomen demonstrating a voluminous liver abscess with an air–fluid level (white asterix). Panel B. Coronal section from a computed tomography scan showing a pneumoperitoneum and a massive subcutaneous emphysema from the abdomen to the head (white arrows). Panel C and D. Transversal section from a computed tomography scan of the cervical© and the thoracic (d) region demonstrating diffuse subcutaneous emphysema (white arrows)

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   Discussion Top


SE is caused by the passage of air beneath the soft tissue mostly after traumatic communication between close cavity containing air (sinuses, trachea, and alveoli) and underlying tissues. In a surgical context, SE may be an iatrogenic consequence of laparoscopy because of the diffusion of the insufflated CO2 gas through subcutaneous tissues.[4] Few cases reported the presence of SE after colonic perforation complicating colonoscopy.[2],[3] Colonic perforation is a rare complication of colonoscopy with an incidence ranging from 0.04% to 0.7%.[2] It can lead to SE only if the perforation involves the extraperitoneal colon.[2] Accordingly, SE is exceptionally present in case of colonic perforation. Among mechanically ventilated and sedated patients, physical examination and interrogation is limited, thus identifying the origin of a SE is challenging for critical care clinicians. In our case, the cause of SE-related colonic perforation remained unknown. In ventilated patients, alveolar rupture due to mechanical ventilation-induced barotrauma must be ruled out. In our case, the CT scan did not reveal SE-associated pneumothorax or pneumomediastinum, arguing against this hypothesis. Our patient demonstrated SE within 12 h following the first laparotomy, consequently a surgical complication was suspected, but the surgeons did not report any difficulties during the first laparotomy surgery. Another explanation is that the perforation could result from colonic ischemia caused by the underlying septic shock. SE itself does not require specific treatment and its associated outcome mainly relies on the underlying etiology. Etiological diagnosis of SE remains the cornerstone of its management.[1] In critically ill ventilated patients, alveolar rupture-related barotrauma is one of the main causes of SE, and its associated complications such as tense pneumothorax or pneumomediastinum must be ruled out. Exceptionally, SE is related to colonic perforation. This unusual presentation can mislead the clinician and delay initiation of the adequate treatment.

In conclusion, our case emphasizes that SE is an exceptional symptom of colonic perforation that should be suspected following recent laparoscopy or colonic procedure while ruling out more common causes such as alveolar rupture and barotrauma. Abdominal CT scan may facilitate diagnosis.

Research quality and ethics statement

This case report did not require approval by the Institutional Review Board / Ethics Committee. The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, specifically the CARE guideline, during the conduct of this research project.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's guardian has given consent for the patient's images and other clinical information to be reported in the journal. The patient's guardian understands that the patient's name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984;144:1447-53.  Back to cited text no. 1
    
2.
Jaafar S, Hung Fong SS, Waheed A, Misra S, Chavda K. Pneumoretroperitoneum with subcutaneous emphysema after a post colonoscopy colonic perforation. Int J Surg Case Rep 2019;58:117-20.  Back to cited text no. 2
    
3.
Weng E, Valencia DN, Krudy ZA, Ali M. Intraperitoneal and extraperitoneal colonic perforation following diagnostic and therapeutic colonoscopy with Crohn's-related stricture dilation. Cureus 2020;12:E7162.  Back to cited text no. 3
    
4.
Murdock CM, Wolff AJ, Van Geem T. Risk factors for hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum during laparoscopy. Obstet Gynecol 2000;95:704-9.  Back to cited text no. 4
    


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