Subcutaneous emphysema, pneumomediastinum and pneumoperitoneum after unsuccessful ERCP: a case report
© Alexiou et al; licensee BioMed Central Ltd. 2009
Received: 21 December 2008
Accepted: 03 February 2009
Published: 03 February 2009
The presence of subcutaneous emphysema, pneumomediastinum and pneumoperitoneum simultaneously is a rare complication of upper gastrointestinal endoscopy that usually indicates free perforation to the peritoneal cavity or the retroperitoneal space.
We report an unusual case of a self-limited subcutaneous emphysema, pneumomediastinum and pneumoperitoneum following an unsuccessful ERCP for removal of a common bile duct stone.
There was no radiological evidence of peritoneal or retroperitoneal perforation. This complication is distinct from pneumomediastinum and pneumoperitoneum due to perforation, and must be recognized, because it is benign and needs no surgical or radiological intervention.
Endoscopic retrograde cholangiopancreatography (ERCP) is a standard invasive technique for revealing and management of a wide spectrum of distal bile duct disorders. The rate of significant complications is very low if it isn't combined with endoscopic sphincterotomy. Subcutaneous emphysema, pneumomediastinum and pneumoperitoneum after endoscopy indicate free perforation resulting from instrumental trauma. We present a case of subcutaneous emphysema, pneumomediastinum and pneumoperitoneum after ERCP without an obvious retroperitoneal or peritoneal perforation.
The presence of pneumomediastinum implies that there is or have been a breach of an air-containing mediastinal structure. Air in the mediastinal tissues may originate from the respiratory tract, such as after blunt or penetrating trauma to the facial bones, pharynx, hypopharynx, trachea and main stem bronchi. Dental procedures – using compressed air – may result to facial and neck subcutaneous emphysema and pneumomediastinum. Severe straining, Valsalva maneuver and free perforation of the gastrointestinal tract may be responsible of the appearance of pneumomediastinum and subcutaneous emphysema .
In free perforation of the gastrointestinal tract, the air may enter from the peritoneal cavity to the mediastinum through the esophageal hiatus and the foramen of Morgagni. However, pneumomediastinum without evidence of perforation has been described after esophagogastroscopy , endoscopic sphincterotomy [1, 3], sigmoidoscopy or colonoscopy [4–7], air contrast barium enema and endoscopic polypectomy [8, 9]. There are also reports for pneumothorax complicating ERCP [10–12].
The most likely explanations for the simultaneous presence of pneumoperitoneum, pneumomediastinum and subcutaneous emphysema in our patient are: (a). The endoscopic tip injured the mucosa of the gastric mucosa or the long afferent limb of the Billroth II gastroenterostomy, allowing insufflated air to enter the wall and dissect along the perineural and perivascular sheaths to reach the mediastinum. (b). High pressure in the closed long afferent limb of the Billroth II gastroenterostomy may have contributed by forcing air through the mucosal break into the interstitial tissues.
Maunder et al described the anatomic route by which peritoneal air results in pneumomediastinum and pneumothoraces . The soft tissue compartment of the neck, thorax and abdomen contains four regions defined as the subcutaneous tissue, prevertebral tissue, visceral space and previsceral space. The visceral space inverts the trachea and esophagus and continues with these structures into the mediastinum and bronchovascular sheaths. It follows the esophagus though the diaphragmatic hiatus into the retroperitoneal and peritoneal soft tissue space. Thus, there is continuity along the neck, thorax and abdomen. Air arising in any one of these regions could reach another area by "traveling" along the fascial planes.
Another explanation has been given by Kirschner, who described and categorized the clinical occurrence of peritoneopleural transphrenic passage of fluids or gases through, either congenital or acquired pores in the diaphragm as porous diaphragm syndromes .
Our patient experienced a mild retrosternal discomfort radiating into the neck. He did not experience respiratory difficulty. The physical examination can reveal crepitus; "Hamman's crunch" (crepitant sound heard at auscultation that varies with heartbeat), ecchymosis, masses, and erythema may be present in the face, neck, or torso. Typically, the history and physical examination are sufficient to determine the mechanism and timing of the injury and the patient's physiologic response.
The best tests to evaluate pneumomediastinum, pneumoperitoneum and subcutaneous emphysema are those that rapidly help to determine the location and size of perforation (if it exists), estimate the degree of contamination and help the clinician to develop a plan of treatment. A chest x-ray and plain abdominal x-rays define the findings, but because of being relatively insensitive, CT of the neck, chest and abdomen should be performed. CT can help to identify the source of mediastinal air. Contrast enhanced fluoroscopy of the pharynx and the esophagogastric region may help detecting the perforation. A water-soluble contrast study with diatrizoate meglumine (Gastrographin) is used to define an esophageal or gastric perforation, but a small leak or tear may seal spontaneously and be missed by this investigation in approximately 10% of the cases. If there is a high suspicion of perforation, a contrast study with dilute barium can detect smaller leaks . Also, laryngoscopy, bronchoscopy and esophagoscopy may be useful to evaluate the damage and plan the management. Our patient underwent all the above examinations, except endoscopy, without being able to detect the site of perforation. Overall, with the above studies still there is a 5% to 10% risk that the perforation is present but not detected. If the clinical suspicion of perforation is high, the studies can be repeated after 12–24 hours, reducing the likelihood of a missed perforation to less than 1% to 2%.
When patients undergo evaluation for pneumomediastinum, the initial management is conservative. They should receive nothing by mouth; gastric aspiration and intravenous broad-spectrum antibiotics are appropriate. Total parenteral nutrition may be indicated. Repeated chest x-rays will document improvement and ensure that progression to pneumothorax will not be missed. If perforation is demonstrated in the imaging studies, surgical repair is indicated [1, 13].
Our case suggests that pneumomediastinum, pneumoperitoneum and subcutaneous emphysema without free esophageal perforation or perforation in the peritoneal cavity or the retroperitoneal space following endoscopy is benign, self-limited and need no surgical or radiological intervention.
We have obtained written, informed consent from the patient for open access publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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