įollowing perforation, symptoms may appear either immediately or after several hours. Possible clinical presentations of this complication also include pneumo-pericardium, periorbital edema and pneumo-scrotum. It is also remarkable that eventually, intestinal perforation is not detected and gas insufflations continue, situation may be complicated with tension pneumo-thorax with adverse outcomes in terms of prognosis and mortality.
In case of rupture of the mediastinal parietal pleura, pneumothorax may occur. From the retroperitoneal level, air is moving next to the fascial plans, mesentery and through the esophageal hiatus passes into the mediastinum and subcutaneous tissues. More specifically, following perforation, intra-luminal air is compressed and it may flee into retroperitoneal or peritoneal cavity. Pathogenesis of the extra-luminal air diffusion secondary to intestinal perforation is attributed to the anatomical continuity between the subcutaneous tissue, the mediastinum and the retro-peritoneum. Thermal injury and electro-coagulation may result in delayed colonic perforation due to ischemia of the colonic wall. With regards to the time of diagnosis, perforations produced from diagnostic colonoscopy (due to the mechanical pressure) are larger and are detected promptly since patients are admitted earlier, while those occurring from therapeutic colonoscopy are diagnosed late and are smaller in size. Perforations may be pneumatic due to excessive distension of the intestinal wall from high-pressure insufflations or mechanic from the pressure exerted by the gastroenterologist.
In a retrospective study on more than thirty thousand patients, it was found to be only 0.1%. Intestinal perforation following colonoscopy represents a rare complication. Imaging studies included chest X-ray and thoracic and abdominal thoracic scans showing pneumomediastinum, pneumoretroperitoneum and subcutaneous emphysema of the neck ( Figures 1 1 – 4). Physical examination disclosed a distended abdomen with diffuse sensitivity on palpation without tenderness and crepitus in the left part of neck and buccal area. Her electrocardiogram revealed sinus rhythm with no abnormal findings. An arterial blood gas analysis showed: pH, 7,48 PaCO2, 25.3 mmHg PaO2, 72.6 mmHg. Biochemical parameters were within normal limits. Urine analysis and urine culture were normal. Laboratory evaluation disclosure included: white blood cell count, 9.90 cells/μL (normal range: 4–11 K/μL) hemoglobin, 13.9 g/dL (normal range: 13.5–17.5 g/dL) hematocrit, 42.1% (normal range: 40–50%) platelet counts, 135 cells/μL (normal range: 150–450 K/μL). Her vital signs were as follows: blood pressure, 125/65 mmHg oxygen saturation 97% while she was breathing ambient air heart rate, 100 per minute temperature, 36.5 degree Celsius. On admission, swelling of the face and neck were noticed. Her past medical history included hypertension and hyperlipidemia. Gastroenterologist reported that the procedure was uneventful. Three hours earlier, she underwent a preventive colonoscopy by a gastroenterologist in a private medical practice in order to evaluate symptoms of abdominal discomfort of 3 months duration. A 62-year-old female was admitted to the emergency department of the Saint George General Hospital of Chania, Crete, Greece complaining of chest and mild abdominal pain.
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