Atypical Presentation of Iatrogenic Colonic Perforation: A Case Report and Review of Previously Reported Cases

Abstract

Introduction: Iatrogenic perforation is the most feared complication of colonoscopy and may lead to peritonitis, septic shock with a mortality rate upto 25%. Although most colonic perforations are intraperitoneal, extraperitoneal perforations have also been reported. However, a combination of both is extremely rare. Here we present one such case of colonic perforation along with comprehensive literature review of previously reported cases. Case Presentation: A 41-year-old Caucasian female with Ulcerative colitis (UC) presented with fever, watery diarrhea and lower abdominal pain for two days. She was in septic shock and was treated with IV antibiotics & fluids. CT scan of abdomen showed diffuse colitis and right pyelonephritis. After she became stable, colonoscopy was performed which revealed colitis in the descending and sigmoid colon. Biopsies were consistent with UC. Next day, she developed subcutaneous emphysema of the chest wall. CT chest, abdomen and pelvis revealed large pneumoperitoneum, pneumomediastinum & pneumopericardium. She was found to have transverse colon perforation and underwent subtotal colectomy with end ileostomy. Discussion: Vast majority of iatrogenic colonic perforation are intraperitoneal, however very few cases of extraperitoneal perforation have also been reported. We analyzed the duration of symptom onset, clinical features, imaging findings, site of leak and treatment administered in 31 cases of Extraperitoneal perforation reported in English literature. Incidence of perforation was similar after both diagnostic & therapeutic colonoscopies. More than half of perforations were detected within first hour of procedure. Most common presenting clinical feature was subcutaneous emphysema of neck, face or upper chest followed by abdominal pain and dyspnea. Few patients remained asymptomatic. Most common site of perforation was recto-sigmoid followed by cecum. Pneumomediastinum was the most common radiological finding followed by pneumothorax and pneumopericardium. More than half of the patients were treated conservatively while rest needed operative management. Conclusion: Physicians should be cognizant of the possibility of extraperitoneal perforation after colonoscopy. Classical abdominal pain may be absent in majority of cases. Colonic perforation should be considered when a patient presents with facial swelling, chest pain &/or shortness of breath post colonoscopy, as early recognition results in better prognosis.Figure 1Figure 2