Chest Pain After Gastrointestinal Endoscopic Examination

Abstract

A 36-year old man was referred to our hospital with intermittent abdominal pain and bloating. Routine gastroduodenoscopy and ileocolonoscopy were performed without any visible signs of pathologic gastric, duodenal, ileal, or colonic mucosa. Routine biopsies were taken from gastric antrum and corpus, proximal duodenum, distal ileum, and from 4 different stages of the colon (ascending, transverse, descending, and sigmoid colon). All biopsies were from macroscopic intact mucosa without any bleeding evidence or visible signs for acute perforation. After an inconspicuous 2-hour observation period the patient was sent home. On the following day the patient returned to our hospital complaining about intense left-sided chest pain with radiation into his left arm. The patient reported that slight chest pain started about 8 hours after demission and worsened over night. On clinical examination, both lung sides were clear on auscultation without signs for pneumothorax, no subcutaneous thoracic emphysema was noted, heart sounds were normal, and the stomach was tender on palpation without any signs of peritonitis. An electrocardiogram, cardiac enzymes, and D dimer were within normal limits. Because of free mediastinal, pericardial, and retroperitoneal air, diagnosis of pneumomediastinum (white arrows, Figure A), pneumopericardium (black arrow, Figure A), and retropneumoperitoneum (white arrow, Figures B and C) was made. The patient was admitted for clinical observation and was designated as nothing per oral for 48 hours. Prophylactic antibiotic therapy (piperacilline/tazobactam) and pain therapy were started. Computed tomography of the chest and abdomen showed no signs for abscess formation. Follow-up x-rays showed gradual reabsorption of free retroperitonal, mediastinal, and pericardial air. Histologic biopsy examinations were normal. After a hospital stay of 4 days, the patient was discharged symptom-free. Retroperitoneal perforation is a rare complication after colonoscopy and gastroduodenoscopy, ranging between 0.1%–1%. Whereas several case reports were found in literature concerning retroperitoneal perforation after endoscopic gastrointestinal examination associated with polypectomy, mucosectomy, or in patients with active inflammatory bowel diseases or colonic cancer, there were only few reports about perforations during routine endoscopic examination and biopsy taking.1Girardi A. Piazza I. Giunta G. et al.Retroperitoneal, mediastinal and subcutaneous emphysema as a complication of routine upper gastrointestinal endoscopy.Endoscopy. 1990; 22: 83-84Crossref PubMed Scopus (20) Google Scholar Possible places for perforation in our case could have been the biopsy sites in the duodenum, ileum, ascending or descending colon. All these parts have total (duodenum) or partial (ileum, ascending/descending colon) retroperitoneal position. In contrast to intraperitoneal perforation with acute peritonitis symptoms and easy recognition on x-ray, retroperitoneal perforation shows initially fewer symptoms and can be easily overlooked on x-ray.2Bejvan S.M. Godwin J.D. Pneumomediastinum: old signs and new signs.AJR Am J Roentgenol. 1996; 166: 1041-1048Crossref PubMed Scopus (175) Google Scholar Most cases can be managed conservatively; a surgical intervention in patients without signs of peritonitis is seldom necessary.3Igbal C.W. Chun Y.S. Farley D.R. Colonoscopic perforations: a retrospective review.J Gastrointest Surg. 2005; 9: 1229-1235Crossref PubMed Scopus (129) Google Scholar