[Pneumoperitoneum, pneumoretroperitoneum, bilateral pneumothorax, pneumomediastinum and subcutaneous emphysema due ERCP]. / Neumoperitoneo, neumoretroperitoneo, neumotórax bilateral, neumomediastino y enfisema subcutáneo secundario a CPRE.

Endoscopic retrograde cholangiopancreatography (ERCP) has become an essential procedure in the diagnosis and treatment of biliopancreatic diseases. Complications of this procedure are potentially serious, being necessary to know how to recognize them for the application of the appropriate treatment. We report the case of a 79-year-old woman who developed a massive subcutaneous emphysema, bilateral pneumothorax, retropneumomediastinum, retropneumoperitoneum and pneumoperitoneum due to iatrogenic duodenal injury secondary to ERCP. The clinical suspicion for early diagnosis of iatrogenic injury after ERCP will determine the correct treatment of this complication and will achieve better outcomes.

Spontaneous rupture of a sigmoid colon gastrointestinal stromal tumor manifesting as pneumoretroperitoneum with localized peritonitis: report of a case.

Colonic gastrointestinal stromal tumors (GISTs) account for only 5%-10% of tumors arising in the digestive tract. Spontaneous rupture is a very rare manifestation of a GIST; however, we report what to our knowledge is the first documented case of pneumoretroperitoneum caused by the rupture of a GIST. A 77-year-old woman was admitted to our hospital with acute abdominal pain and hematochezia. Colonoscopy showed luminal narrowing in the sigmoid colon, but no definite mucosal defect. Computed tomography (CT) showed an air-containing heterogeneous mass, 9.7 × 9.3 cm, in the pelvic cavity and a small amount of air in the retroperitoneum. Emergency laparotomy revealed a ruptured sigmoid colonic GIST with localized peritonitis. Pathologic examination confirmed that the tumor was composed mainly of round epithelioid cells. It was immunohistochemically positive for CD34 and negative for C-kit protein. This report describes how we successfully managed pneumoretroperitoneum with localized peritonitis caused by the spontaneous rupture of an epithelioid GIST originating from the sigmoid colon.

Tension pneumothorax, pneumoretroperitoneum, and subcutaneous emphysema after colonoscopic polypectomy: a case report and review of the literature.

BACKGROUND AND AIMS: Colonoscopic complications are not frequent. Cases with colon perforations without the presence of pneumoperitoneum are very rare, and those with the development of tension pneumothorax are even rarer. The aim of this article was to present a unique case of the colon perforation during colonoscopic polypectomy. CASE REPORT: We report a unique case of the colon perforation made between the two layers of the sigmoid mesocolon during colonoscopic polypectomy. The colon perforation had not been recognized during colonoscopic polypectomy, but the patient stayed at the hospital to be observed for the possible remitted bleeding after polypectomy. The colon perforation was followed by the development of the left-sided tension pneumothorax with massive mediastinum tending to move to the right, pneumoretroperitoneum, subcutaneous emphysema of the head, neck, and body, but without pneumoperitoneum. Tube drainage of the left pleural cavity was performed with release a great amount of air under pressure and then an urgent laparotomy when there was no free gas in the peritoneal cavity. After mobilizing the sigmoid colon, pneumoretroperitoneum and sigmoid colon perforation of 1.5 mm in diameter between two mesosigmoid layers were discovered. Partial sigmoidectomy was performed. A pathohistological examination verified a deepithelized area of 12 mm and a perforation of 1.5-mm diameter. The patient was dismissed as recovered 7 days after. CONCLUSION: The patient was well prepared for colonoscopy, without other general diseases, and operated on quickly after the perforation (within 2 h from the perforation), without any significant retroperitoneum contamination. These are the factors for a favorable outcome of the treatment.

Tension pneumothorax after endoscopic retrograde pancreatocholangiogram.

We report a case of tension pneumothorax after an endoscopic sphincterotomy. A 78-yr-old woman presented with progressing dyspnea. She had undergone an endoscopic retrograde cholangiopancreatogram three days before due to acute cholecystitis. She underwent endoscopic sphincterotomy for stone extraction, but the procedure failed. On arrival to our hospital, she complained about severe dyspnea and she had subcutaneous emphysema. A computed tomogram scan revealed severe subcutaneous emphysema, right-side tension pneumothorax, and pneumoretroperitoneum. Contrast media injected through a transnasal biliary drainage catheter spilled from the second portion of the duodenum. A second abdominal computed tomogram showed multiple air densities in the retroperitoneum and peritoneal cavity, which were consistent with panperitonitis. We recommended an emergent laparotomic exploration, but the patient's guardians refused. She died eventually due to septic shock. Endoscopic retrograde cholangiopancreatogram is a popular procedure for biliary and pancreatic diseases, but it can cause severe complications such as intestinal perforation. Besides perforations, air can spread through the abdominal cavity, retroperitoneum, mediastinum, and the neck soft tissue, eventually causing pneumothorax. Early recognition and appropriate management is crucial to an optimal output of gastrointestinal perforation and pneumothorax.

Retroperitoneal, mediastinal, and subcutaneous emphysema, complicating colonoscopy and rectal polypectomy.

Complications of flexible endoscopy-though still rare-are increasing in frequency lately as more invasive procedures are routinely performed. Perforation, hemorrhage, coagulation disorders, thrombophlebitis, and splenic rupture have all been reported to complicate colonoscopy and colorectal polypectomies. In this paper, we report on a case of retroperitoneal, mediastinal, and neck surgical emphysema, complicating colonoscopy and rectal polypectomy, presented initially as a change in the voice and facial swelling.

Pneumoretroperitoneum, Pneumomediastinum, Pneumothorax, and Subcutaneous Emphysema after Diagnostic Colonoscopy.

Colonoscopy is a commonly performed endoscopic procedure. Although it is generally considered to be safe, serious complications, such as colorectal perforation, can occur. Most colonic perforations are intraperitoneal and cause pneumoperitoneum with acute abdominal pain as the initial symptom. However, extraperitoneal perforations with pneumoretroperitoneum may happen, albeit rarely, with atypical initial symptoms. We report a rare case of rectosigmoid perforation occurring after diagnostic colonoscopy that developed into pneumoretroperitoneum, pneumomediastinum, pneumothorax, and subcutaneous emphysema, with a change in voice and neck swelling as the initial symptoms. The patient was successfully treated with endoscopic closure of the perforation and conservative management.

Barotrauma.

Barotrauma remains a significant complication of mechanical ventilation, particularly in ARDS. A number of alternative techniques for mechanical ventilation are being investigated with the purpose of minimizing ventilator-related lung injury and air leak phenomena while maintaining adequate oxygenation. Among them pressure-controlled inverse-ratio ventilation and extracorporeal carbon dioxide removal have not resulted in a definite reduction of barotrauma thus far. The radiologist plays an important role in the early recognition of barotrauma and may assist in the treatment of its sequelae.

[Benign non-organ-related diseases of the retroperitoneal space]. / Benigne, nicht organgebundene Erkrankungen des Retroperitonealraumes.

Because of the anatomic localisation of the retroperitoneal space, the detection and elucidation of pathology in the retroperitoneum calls for clinical acumen and the utilisation of imaging techniques. During the past two decades, efforts spearheaded by the work of M. A. Meyers led to an enhanced understanding of retroperitoneal anatomy and pathology. Conventional radiographic techniques are often incapable of detecting and/or characterising retroperitoneal abnormalities. Sonography may be limited by patient-dependent-factors. CT is unaffected by bowel gas and provides discrete cross-sectional images of the organs, fascial planes and retroperitoneal compartments, making it an ideal tool for assessment of retroperitoneal disease. In clinically stable patients MRT may be a useful modality for providing helpful and additional information in characterising retroperitoneal abnormalities. In this review article the diagnostic possibilities of benign not organ-related diseases of the retroperitoneum are described. This is intended to give the reader an insight into the etiology and distribution patterns of retroperitoneal fluid and gas collections as well as into diagnosis and differential diagnosis of benign retroperitoneal diseases. The diagnostic impact of the different imaging modalities is discussed.

[Pneumoretroperitoneum due to pneumatosis cystoides intestinalis. An etiopathogenetic and clinico-diagnostic assessment. A clinical case report]. / Pneumoretroperitoneo da pneumatosi cistica intestinale. Valutazioni etiopatogenetiche e clinico-diagnostiche. Presentazione di un caso clinico.

A case of pneumoretroperitoneum which came out to be caused by pneumatosis cystoides intestinalis, after careful and proper diagnostic evaluation, is described. Physiopathology, etiopathogenesis and clinical peculiarities of this infrequent pathology are examined; most useful tests to be performed in diagnostic differential evaluation, and clinical and surgical therapeutic approaches are also described, especially facing rare complications of PCI, such as pneumoperitoneum and pneumoretroperitoneum.

[Pneumatosis cystoides intestinalis in systemic diseases: 3 cases]. / Pneumatose kystique intestinale au cours d'une maladie systémique. 3 observations.

BACKGROUND: Pneumatosis cystoides intestinalis (PCI) is usually a complication of digestive tract or respiratory tract diseases, but rare cases have been described in systemic diseases, mainly systemic sclerosis. CASE REPORTS: Three patients, one with temporal arteritis and two with polyarteritis nodosa (complicating rheumatoid arthritis in one case) were treated by prednisone. All three developed PCI, complicated in one case by a retropneumoperitoneum. Medical treatment led to a favorable outcome in all cases. DISCUSSION: Sixty-two cases of PCI have been reported in patients with various systemic diseases (systemic sclerosis, systemic lupus erythematosus, mixed connective tissue disease, dermatopolymyositis, polyarteritis nodosa, rheumatoid arthritis, Sjögren's syndrome, amyloidosis). Systemic sclerosis is the most frequent condition (45%). In the other cases, corticosteroid therapy or digestive tract vasculitis are the main causal factors. Outcome is usually favorable with medical treatment. Laparotomy is rarely needed.

Tension pneumothorax complicating endoscopic retrograde cholangiopancreatography: case report and systematic literature review.

Perforation of the duodenum, which is usually retroperitoneal, is a known complication of endoscopic retrograde cholangiopancreatography (ERCP). Association of the duodenal perforation with pneumothorax is rare and the development of tension pneumothorax is even rarer. We report a case of tension pneumothorax following an ERCP, which we successfully treated with chest tube insertion and laparotomy, and systematically review the other 10 cases reported in the literature. Four of these 10 cases had tension pneumothorax. All were to the right side of the chest. Patients were mainly female (7/10). The median (range) age was 70.5 (55-89) years. Four patients required surgery (40%) and one patient, who was not operated on, died (10%). Clinicians should be aware of this serious complication. Unexplained chest pain, dyspnoea, and oxygen desaturation with abdominal distension during ERCP must raise this possibility. Early clinical recognition and prompt management is essential to improve the outcome.

[Pneumoretroperitoneum and bilateral pneumothorax after endoscopic biliary sphincterotomy]. / Pneumoretroperitoneum und beidseitiger Pneumothorax nach endoskopischer Sphinkterotomie.

HISTORY AND ADMISSION FINDINGS: A 39-year-old obese woman underwent endoscopic retrograde cholangiopancreatography with elective endoscopic biliary sphincterotomy (papillotomy) for symptomatic retained stones in the common bile duct which were extracted completely after added lithotripsy. Three hours later the patient developed profound subcutaneous emphysema of the face, neck and chest wall and shortness of breath, but had no abdominal pain. Physical examination revealed bilaterally diminished breath sounds and a distended and hyper-resonant abdomen, but no evidence of peritonitis. The patient was afebrile and hemodynamically stable. INVESTIGATIONS: An emergency contrast-enhanced computed tomography (CT) of the chest and abdomen was performed. It demonstrated a bilateral pneumothorax, pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum, in addition to extensive subcutaneous emphysema. There was no evidence of extraluminal leakage of contrast medium or intraperitoneal fluid on the CT. THERAPY AND CLINICAL COURSE: Because of the increasing respiratory distress an intercostal drain was placed in the left pneumothorax and broad-spectrum antibiotics were administered. No drain was placed in the right lung. A follow-up CT after three days showed decreasing pneumomediastinum, pneumoperitoneum and pneumoretroperitoneum as well as resolution of the bilateral pneumothorax. The patient made an uneventful recovery and was discharged home seven days after the intervention. CONCLUSION: Pneumothorax after endoscopic biliary sphincterotomy is a rare but serious complication that should be kept in mind after postinterventional development of shortness of breath.