Intraperitoneal Perforation Research Articles

Strangulated direct inguinal hernia with intraperitoneal perforation

Usually direct inguinal hernia doesn’t present as strangulation or incarceration as compared to indirect inguinal hernia because of earlier has wider neck. A patient of recurrent direct inguinal hernia presents as intra-scrotal gangrene and intra-peritoneal perforation. We reported a case of 65 years old male presented with septicemia and right sided strangulated direct hernia. On exploration through inguino scrotal incision and mid line laparotomy, gangrenous loop was found in scrotum and perforation was found in intra-peritoneal part of small intestine. Resection-anastomosis was done for both the parts of intestine. Inguinal Incision was closed by posterior wall closure and modified Bassini’s herniorraphy. Abdomen was closed in layers with brain. Long standing direct hernia may present as strangulation or incarceration specially in elderly but perforation and gangrene of intra-peritoneal part of small intestine is very rare.

Intraperitoneal Urinary Bladder Perforation with Pneumoperitoneum in Association with Indwelling Foley Catheter Diagnosed in Emergency Department

BackgroundIndwelling Foley catheter is a rare cause of urinary bladder perforation, a serious injury with high mortality that demands accurate and prompt diagnosis. While the gold standard for diagnosis of bladder injury is computed tomography (CT) cystography, few bladder ruptures associated with Foley catheter have been reported to be diagnosed in the emergency department (ED). Case ReportAn 83-year-old man with indwelling Foley catheter presented to the ED for hematuria and altered mental status. He was diagnosed to have intraperitoneal rupture of the urinary bladder in the ED using abdominal and pelvic CT without contrast, which demonstrated bladder wall discontinuity, intraperitoneal free fluid, and pneumoperitoneum. The patient was treated successfully with medical management and bladder drainage. Why Should an Emergency Physician Be Aware of This?To our knowledge, this is the first report of intraperitoneal urinary bladder perforation associated with Foley catheter diagnosed in the ED by CT without contrast. Pneumoperitoneum found in this case was a clue to the diagnosis and is a benign finding that does not necessitate urgent surgical intervention. The early and accurate diagnosis in this case allowed for effective management with good clinical outcome. The use of indwelling Foley catheter has a high prevalence, especially in long-term care facility residents, who are frequent visitors in the ED. Therefore, emergency physicians and radiologists should be familiar with the presentation and imaging findings of this potential injury associated with Foley catheters.

Minimal access surgery in the management of pediatric urolithiasis.

In contrast to adult patients, a relatively large number of open surgical procedures are still needed in the treatment of urolithiasis in children. Since almost all open surgical techniques may be reproduced by minimal access surgery (MAS), there is a rationale to apply the latter in the management of pediatric urolithiasis. Our study aimed to assess the feasibility and outcome of MAS in the treatment of pediatric urinary calculi. The charts of patients with urolithiasis submitted to MAS between 1994 and 2007 were retrospectively reviewed. The inclusion criteria were contraindication for and failure of lithotripsy or endourology techniques. Demographic data, lithiasis characterization (location, dimension, composition), predisposing factors (anatomic or metabolic) and surgical approach (technique and outcome) were evaluated. Fifteen consecutive patients (eight girls, seven boys) with a median age of 108 months (range: 10-297 months) were elected for MAS. Eleven (73%) children had associated urogenital malformations and three (20%) presented metabolic abnormalities. A total of 17 procedures were performed laparoscopically: three nephrolithotomy (one transperitoneal, two by retroperitoneoscopy), four pyelolithotomies (retro), three ureterolithotomy (trans) and seven cystolithotomies (suprapubic approach). Five patients underwent concomitant correction of urological anomalies (three calyceal diverticula, one obstructive megaureter, one ureteropelvic junction obstruction). Complete removal of calculi was accomplished in 14 (82%) procedures. There were two perioperative complications (one intraperitoneal vesical perforation and one perivesical urinoma). At a median follow up of 4 years (range, 1 month to 11 years), four patients have developed recurrence. MAS is an effective and safe approach for urolithiasis in children who are not candidates for minimally invasive modalities.

Spontaneous rupture of the bladder during vomiting

A 46-year-old woman with no urological history or comorbidities presented with an acute abdomen with haematuria after a spell of protracted vomiting. The initial cystogram was negative; however, CT imaging...

Intraperitoneal Bladder Perforation Due to Clean Intermittent Catheterization: A Case Report and Literature Review

Intraperitoneal Bladder Perforation Due to Clean Intermittent Catheterization: A Case Report and Literature Review

Gastropleural Fistula: A Rare Cause of Intractable Upper Gastrointestinal Hemorrhage

Case Presentation: A 48-year-old Caucasian man with history of alcohol abuse, type II diabetes mellitus, hypertension, and multiple abdominal surgeries (partial gastrectomy, partial pancreatectomy, splenectomy and partial left nephrectomy) was transferred to our center for management of melena and shortness of breath. A computed tomography report from outside hospital (OSH) suggested dense material in the stomach and a left lung cavitary lesion, but images were not available for our review. Bronchoscopy revealed remnants of digested food in the left bronchial tree, which was attributed to aspiration at OSH. Soon after arrival to our facility, the patient developed an episode of large hematemesis requiring emergent intubation. GI was consulted for EGD, which did not suggest any gastric cause of bleeding, but a fistulous tract was recognized. Urgent repeat bronchoscopy revealed complete occlusion of the left main bronchus with a visible blood clots and food material. An arteriogram identified the source of the bleeding to be the left pulmonary and bronchial artery, but embolization was not successful and patient was taken for a thoracotomy and lung resection. Intra-operatively, a large abscess was found in the left pleural space with a communicating fistula to the stomach through a diaphragmatic defect. The fistula, gastric wall, and diaphragmatic defect were all successfully repaired and patient recovered well. Discussion: Gastropleural fistula is a rare but potentially lethal condition, which may occur as a complication involving one of three different mechanisms: perforation of the stomach (intrathoracic portion of hiatal hernia), traumatic event to the stomach or lung, or an intraperitoneal gastric perforation with erosion of a subphrenic abscess via the diaphragm. The cause of gastropleural fistula in our case is unclear. One possibility is aspiration pneumonia complicating into abscess, which eroded through the diaphragm into the stomach. Alternate etiology could be gastric in origin, whereby an ulcer eroded through an already adhesed area of a postsurgical stomach into the left lower lobe of the lung. It is important for gastroenterologists and endoscopists to remain cognizant about prior surgical histories, while managing patients with gastrointestinal hemorrhage because many of them may present with complications like gastropleural fistulae decades later.Figure 1Figure 2Figure 3

OC-047 New Platform for Trans-Anal Submucosal Endoscopic Resection- (TASER): Updated Clinical Results from Tertiary Centre

Introduction Current trans-anal surgical and advanced endoscopic resection procedures have the potential to resect complex rectal polyps (CRPs). However both approaches have limitations in terms of practicality and safety. Methods Consecutive patients (Jan13/April15), referred for the excision of CRPs, were being considered for proctectomy and/or had failed conventional endoscopic/trans-anal therapy. The GelPoint Path trans-anal access port allowed dynamic tissue manipulation to facilitate endoscopic-submucosal-dissection/ESD. Supplementary techniques were also used: piecemeal-endoscopic-mucosal-resection or ablation/P-EMR or EMA and trans-anal excision/TAE. The aim of this study was to evaluate the feasibility, technical success and safety profile of this new hybrid, endo-surgical Trans-Anal Submucosal Endoscopic Resection- (TASER) approach for CRPs. Results Thirty-two TASER procedures were employed in 31 patients (mean age 65 years/17 males-14 females) with 31 CRPs (mean size 8 cm/range 5 cm–18 cm). Complete endoscopic excision in a single session was achieved in 28/31 patients (93%); in one patient a second TASER session for completion of polypectomy, in another an elective laparoscopic-anterior-resection due to T1,sm3,N0,M0 and in a third patient a defunctioning-ileostomy due to intraperitoneal perforation before completion of polypectomy. Mean procedure time was 185 min, range 65–480 min. Thirty two TASER sessions were employed using ESD in 12/32, ESD+P-EMR in 6/32, ESD+P-EMR+EMA in 4/32, ESD+TAE in 3/32, ESD/P-EMR/TAE in 3/32 and ESD+P-EMR+EMA+TAE in 4/32. Intra-procedural bleeding was controlled with haemostatic endoscopic devices/surgical clipping. In 6/10 TASER-TAE cases there was a need for a full-thickness rectal dissection due to severe submucosal fibrosis: 4/6 cases were closed with surgical sutures/endoscopic clips and in 2/6 cases only endoscopic clips were deployed. Two episodes of delayed bleeding were reported with no transfusion/re-intervention requirement. All patients were discharged the day after the TASER apart from one patient who developed bacteremia requiring intravenous antibiotics/a 4 night hospital stay and the patient who required a defunctioning ileostomy, discharged on day 4 post-operation. First follow-up performed at 4–6 months interval in 25/31 patients showed: 21/25 with no recurrence/(84%) and 4/25/ (16%) with a minimal ( Conclusion TASER appears to be a safe and efficient endo-surgical approach providing an optimal platform for the minimally-invasive management of high- risk, complex rectal polyps. Disclosure of Interest None Declared

INTRAPERITONEAL RECTAL PERFORATION PRESENTING AS FETAL ASCITES – A RARE OCCURRENCE

Spontaneous perforation of the rectum presenting as fetal ascites is an extremely rare occurrence. We report the case of an infant where antenatally detected fetal ascites was attributable to intraperitoneal rectal perforation. Investigations directed to identify common causes of this condition did not reveal any aetiology. Patient underwent surgical colostomy formation on day two of life, which was reversed at six weeks of age. We suggest that meconium ascites and peritonitis should be considered as differential diagnoses in fetuses with ascites and, if the neonate requires a laparotomy, the rectal area should be thoroughly inspected to exclude this entity.

TAMIS for rectal tumors: advancements of a new approach.

TAMIS allows transanal excision of rectal lesions by the means of a single-incision access port and traditional laparoscopic instruments. This technique represents a promising treatment of rectal neoplasms since it guarantees precise dissection and reproducible approaches. From May 2010 to September 2015, we performed excisions of rectal lesions in 55 patients using a SILS port. The pre-operative diagnosis was 26 tumours, 26 low and high grade displasias and 3 other benign neoplasias. 11 patients had a neoadjuvant treatment. Pneumorectum was established at a pressure of 15-20mmHg CO2 with continuous insufflation, and ordinary laparoscopic instruments were used to perform full thickness resection of rectal neoplasm with a conventional 5-mm 30° laparoscopic camera. The average operative time was 78min. Postoperative recovery was uneventful in 53 cases: in one case a Hartmann procedure was necessary at two postoperative days due to an intraoperative intraperitoneal perforation; in another case, a diverting colostomy was required at the five postoperative days due to an intraoperative perforation of the vaginal wall. Unclear resection margins were detected in sixpatients: thereafter five patients underwent radical surgery; the other patient was unfit for radical surgery, but is actually alive and well. Patients were discharged after a median of 3days. Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for low rectal tumors. The feasibility of TAMIS also for malignant lesions treated in a neoadjuvant setting could be cautiously evaluated in the future.

Intraperitoneal Bladder Perforation and Life-threatening Renal Failure in a Neonate Following Circumcision With the Plastibell Device

We present the case of an infant who suffered intraperitoneal bladder perforation secondary to routine neonatal circumcision with the Plastibell device. On day-of-life 5, the patient presented with abdominal distention, vomiting, diarrhea, and severe acute renal failure. After removal of a distal meatal obstruction caused by the Plastibell device and open repair of the bladder defect, the patient had an uneventful recovery with rapid return of renal function. Despite the relative safety of the Plastibell, this case underscores the importance of careful device placement, parental education, keen clinical judgment, and prompt intervention when indicated.

MDCT and clinicopathological features of small bowel gastrointestinal stromal tumours in 102 patients: a single institute experience.

Small bowel (SB) is the second most common site of gastrointestinal stromal tumours (GISTs). We evaluated clinical presentation, pathology, imaging features and metastatic pattern of SB GIST. Imaging and clinicopathological data of 102 patients with jejunal/ileal GIST treated at Dana-Farber Cancer Institute and Brigham and Women's Hospital (Boston, MA) between 2002 and 2013 were evaluated. Imaging of treatment-naive primary tumour (41 patients) and follow-up imaging in all patients was reviewed. 90/102 patients were symptomatic at presentation, abdominal pain and lower gastrointestinal blood loss being the most common symptoms. On pathology, 21 GISTs were low risk, 17 were intermediate and 64 were high risk. The mean tumour size was 8.5 cm. On baseline CT (n = 41), tumours were predominantly well circumscribed, exophytic and smooth/mildly lobulated in contour. Of 41 tumours, 16 (39%) were homogeneous, whereas 25 (61%) were heterogeneous. Of the 41 tumours, cystic/necrotic areas (Hounsfield units < 20) were seen in 16 (39%) and calcifications in 9 (22%). CT demonstrated complications in 13/41 (32%) patients in the form of tumour-bowel fistula (TBF) (7/41), bowel obstruction (4/41) and intraperitoneal rupture (2/41). Amongst 102 total patients, metastases developed in 51 (50%) patients (27 at presentation), predominantly involving peritoneum (40/102) and liver (32/102). 7/8 (87%) patients having intraperitoneal rupture at presentation developed metastases. Metastases elsewhere were always associated with hepatic/peritoneal metastases. At last follow-up, 28 patients were deceased (median survival, 65 months). SB GISTs were predominantly large, well-circumscribed, exophytic tumours with or without cystic/necrotic areas. Complications such as TBF, bowel obstruction and intraperitoneal perforation were visualized at presentation, with patients with perforation demonstrating a high risk of metastatic disease. Exophytic eccentric bowel wall involvement and lack of associated adenopathy are useful indicators to help differentiate GISTs from other SB neoplasms. SB GISTs are predominantly large, well-circumscribed, exophytic tumours, and may present with complications. They often are symptomatic at presentation, are high risk on pathology and metastasize to the peritoneum more commonly than the liver.

Colon perforation related to percutaneous nephrolithotomy: from diagnosis to treatment.

We present our experience with the largest series of colon perforation (CP) as complication of percutaneous nephrolithotomy (PNL). From January 1998 to August 2014, 22 cases that presented with PNL-related CP from seven referral centers were retrospectively reviewed. The patients with CP were evaluated in terms of probable risk factors. Peri-operative and postoperative findings, timing of diagnosis, and treatment modalities of the CP were reviewed. Of the 22 patients, previous ipsilateral renal surgery (n:2) and retrorenal colon (n:5) were the risk factors for CP. The CP was directly visualized via nephroscopy during the surgery in 3 (13.6%) and with nephrostography at the end of the procedure in 4 patients (18.2%). In two patients, perforation was realized via the passage of contrast into the colon with nephrostography on the postoperative second day. Postoperative passage of feces through the nephrostomy tube was seen in six patients. The clinical signs in 13 cases directed CP diagnosis. The confirmation of the CP was achieved with a CT scan in all the patients. The patients with extraperitoneal perforation were primarily managed conservatively. Open surgical treatment was performed in cases with intraperitoneal perforation (n:5) and those with extraperitoneal perforation resistant to conservative treatment (n:5). Meticulous evaluation of the risk factors preoperatively is the initial step in the prevention of CP. Timely diagnosis plays essential role in the management of this PNL complication. Although extraperitoneal CP may be managed conservatively, surgery is required for intraperitoneal CPs.

Rhabdomyolysis and acute renal failure following transurethral resection of bladder tumor

s / Urological Science 26 (2015) S50eS81 S80 Results: There were 6 patients in intraperitoneal group and 6 patients in extraperitoenal group with a mean age of 44.5 and 43.2 in each group. Mechanisms of injury were blunt abdominal trauma and pelvic fracture. There was no significant difference between the IBP and EBP groups with regard to age, mechanism of injury, baseline creatinine and blood urea nitrogen (BUN). The biochemical parameters were found to be within normal range in the EBP group, whereas significantly higher levels of creatinine, BUN were noted in IBP group (p 1⁄4 0.01 and 0.06) Conclusion: In patients with intraperitoneal bladder perforation, progressive urinary ascites with the development of abdominal discomfort will soon follow. This is because the excretion function of the kidney greatly exceeds the subdiaphragmatic lymph flow, which provides the principal means for the removal of intraperitoneal fluid. Stasis of urine in the peritoneal cavity allows for reversed intraperitoneal autodialysis to take place. The higher concentration of creatinine and nitrogenous waste products in the urine as compared to plasma allows for concentration gradient diffusion when the urine is in contact with the peritoneum, functioning as a semipermeable membrane. As illustrated in this study, the patient's serum creatinine and BUN will rise. But because the glomerular filtration rate is intact, the raise of serum creatinine is referred to as pseudorenal failure. When pseudorenal failure based on reversed autodialysis is suspected, the intraperitoneal bladder perforation should be considered in differential diagnosis. Further study such as cystography is warranted in these patient and it can identifies a bladder tear by documenting intraperitoneal contrast leakage. patients presenting with IBP are more likely to present with significantly higher levels of creatinine and BUN compared with the patients with EBP. Biochemical alterations can be used to differentiate traumatic IBP and EBP with subtle physical examination and radiological findings. NDP115: RHABDOMYOLYSIS AND ACUTE RENAL FAILURE FOLLOWING TRANSURETHRAL RESECTION OF BLADDER TUMOR Jen-Hao Cheng, Cheng-Che Chen, Yen-Chuan Ou. Divisions of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung,

Serum creatinine for differentiating traumatic intraperitoneal and extraperitoneal bladder perforation

以血中肌肝酸濃度來分別創傷性腹腔內外膀胱破裂 高正立 高建璋 曹智惟 唐守宏 蒙恩 吳勝堂 查岱龍 于大雄 張聖原 孫光煥 1 高建璋 1 三軍總醫院 外科部 泌尿外科 ,國軍桃園總醫院 外科部 泌尿外科 ;台北市立聯 合醫院 泌尿科 3 Serum creatinine for differentiating traumatic intraperitoneal and extraperitoneal bladder perforation Cheng-Li Kao 1,2 , Chien-Chang Kao 1 , Chu-Wei Tsao 1 , Shou-Hung Tang 1 , En Meng 1 , Sheng-Tang Wu 1 , Tai-Lung Cha 1 , Dah-Shyong Yu 1 , Sun-Yran Chang 3 , Guang-Haun Sun 1 ,Chien-Chang Kao 1 Guang-Haun Sun 1

An Uncommon Cause of Abdominal Pain and Fever in a Patient With Crohn’s Disease

Question: A 46-year-old man with a history of ileocolonic Crohn’s disease (CD) presented with worsening abdominal and back pain, fever, and headache. He was diagnosed with CD 16 years ago, when he presented with suspected perforated appendicitis and found to have free intraperitoneal perforation from Crohn’s ileitis for which he underwent ileocecal resection. He did well postoperatively for about 10 years. He developed recurrent CD and was treated with infliximab and azathioprine until 5 months ago, when he developed periumbilical abdominal pain and back pain.

Cross-sectional imaging of common and unusual complications after endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography (ERCP) is currently a primarily therapeutic procedure that is extensively employed to treat several biliopancreatic disorders. Although widely considered a safe procedure, ERCP is associated with a non-negligible morbidity and occasional mortality. Due to the number and complexity of operative ERCPs performed, radiologists are increasingly faced with urgent requests for investigation of suspected post-procedural complications, which often have similar clinical and laboratory manifestations. This pictorial essay reviews the usual post-procedural CT findings, the clinical features and imaging appearances of common and unusual post-ERCP occurrences including interstitial oedematous and necrotising acute pancreatitis, haemorrhages, retroperitoneal and intraperitoneal duodenal perforations, infections and stent-related complications. Emphasis is placed on the pivotal role of multidetector CT, which is warranted after complex or prolonged ERCP procedures as it represents the most effective modality to detect and grade ERCP-related complications and to monitor nonsurgically treated patients. Timely diagnosis and optimal management require a combination of clinical and laboratory data with imaging appearances; therefore, this article aims to provide an increased familiarity with interpretation of early post-ERCP studies, particularly to triage those occurrences that require interventional or surgical treatment. In selected patients MRI allows imaging pancreatitis and abnormal collections without the use of ionising radiation. Teaching Points • Endoscopic retrograde cholangiopancreatography (ERCP) allows treating many biliopancreatic disorders.• Due to the number and complexity of procedures, post-ERCP complications are increasingly encountered.• Main complications include acute pancreatitis, haemorrhages, duodenal perforation and infections.• Diagnosis and management of complications rely on combined clinical, laboratory and imaging data.• Multidetector CT is most effective to diagnose, categorise and monitor post-ERCP complications.

Bladder perforations in children.

Bladder perforations in children occur due to several different reasons. In this clinical series study, we focused on bladder perforations due to the pelvic injury, and our aim also was to create awareness for a rare type of bladder injuries. This was a retrospective study of the patients who were treated in our clinic for bladder perforation between 2006 and 2011. We reviewed the documents of childhood bladder perforations, and demographic and clinical characteristics of the patients were obtained. No statistical analyses were used because of the limited number of cases. There were ten patients who suffered from bladder perforation in 5-year period; 5 were male, and 5 were female. The mean age of the patients was 4.35 years. Four patients (40%) experienced iatrogenic perforation and six patients (60%) experienced perforation due to the accident. Common symptoms were hematuria, abdominal tenderness, and inability to urinate. Three patients were diagnosed via emergency laparotomy, without any radiological examinations performed before surgery. Four patients suffered from the intraperitoneal perforation, three patients suffered from extraperitoneal injury and three of them both of intraperitoneal and extraperitoneal injuries. Mean recovery time for patients was 15 days. One patient developed a urinary tract infection and one newborn died due to accompanying morbidities. Nine patients were discharged from the hospital. If the patients had a pelvic injury, surgeons must pay attention for the bladder perforation. Isolated bladder perforations are rare, and they are generally associated with iatrogenic injuries. Clinicians should pay attention to findings such as anuria, inability to insert a urinary catheter, and free fluid in the abdomen in order to diagnose the bladder perforation in newborns. Novice surgeons should pay more attention to avoid causing iatrogenic bladder perforation during inguinal hernia repair.

Delayed spontaneous perforation of urinary bladder with intraperitoneal seeding following radical transurethral resection of invasive urothelial cancer: a case report

BackgroundTransurethral resection of bladder tumor (TURBT) may be applicable for the treatment of deeply invasive tumors in high-risk patients who are not suitable candidates for radical cystectomy. Intraperitoneal perforation is much less common, however, bladder wall perforation is still a cause for concerns because after perforation several studies have been reported to have peritoneal or abdominal metastases.Case presentationAn 84-year-old female patient with multiple large enhancing masses in the urinary bladder underwent radical TURBT to remove the deeply invasive tumors because she was not a suitable candidate for a major operation. Microscopic examination of the resected specimen confirmed the muscle invasive urothelial carcinoma with partial invasion into the perivesical fat tissue. She visited again 6 months later after the operation complaining abdominal distension. Computed tomography showed perforation of urinary bladder with intraperitoneal seeding and adnexa metastasis.ConclusionRadical TURBT could be associated with delayed perforation of urinary bladder and intraperitoneal seeding.

Intraperitoneal and Extraperitoneal Colonic Perforation Following Diagnostic Colonoscopy

Both intraperitoneal and extraperitoneal colonic perforations have been reported after colonoscopy; however, cases with combined types of perforation are rare. We present the case of a 55-year-old man with a history of Crohn disease who complained of acute abdominal pain after a diagnostic colonoscopy. Abdominal computed tomography scan showed extensive pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum, and leftsided pneumothorax. Exploratory laparotomy was performed, and the patient underwent subtotal colectomy and end ileostomy with placement of a left-sided chest drain for the left-sided pneumothorax. The patient was discharged home postoperatively in good condition. As the utility of colonoscopy continues to broaden, its complications will also be more common. Whereas intraperitoneal perforation is a known and not uncommon complication, extraperitoneal perforation is an uncommon complication. Combined intraperitoneal and extraperitoneal perforation is extremely rare, with only a few cases reported in the literature. Early diagnosis and operative management resulted in a satisfactory outcome in this particular case.

Pneumomediastinum and Subcutaneous Emphysema Complicating Colonoscopy

Purpose: Colonoscopy, a widely used procedure for diagnostic and therapeutic purpose, is relatively safe, but not free of complications, among which perforation is common, with 0.4-1.9% incidence. We report a case of colonic perforation presenting with subcutaneous emphysema, pneumomediatinum, and pneumoretroperitoneum complicating therapeutic colonoscopy. Case: A 62-year-old man underwent colonoscopy for evaluation of hematochezia of 1 month's duration. He had multiple colon polyps throughout the colon. Hot snare polypectomy was performed on an isolated right colon polyp, with the rest being removed with a biopsy or cold snare polypectomy. Immediately post procedure, he complained of severe pressure-like chest pain with no associated nausea, dyspnea, diaphoresis, or dizziness. He was noted to develop subcutaneous emphysema involving the neck and left shoulder. Oxygen saturation was 96% on room air. Cell count, comprehensive panel, and cardiac enzymes were normal. EKG showed no evidence of ischemia. Chest x-ray showed sub-diaphragmatic free air. CT scan showed extensive subcutaneous air in the lower part of the neck and mediastinum, along with a large amount of retroperitoneal air dissecting mesentery and around the liver. Free intraperitoneal air was not noted. He was evaluated by surgery service and admitted for observation and conservative management. Due to worsening abdominal pain and tenderness on palpation, he underwent emergent exploratory laparotomy, which did not reveal any evidence of bowel perforation. A colonic perforation was suspected, but not identified. It was postulated that a microperforation had closed spontaneously after decompression of the bowel. The patient continued to do well, and recovered from surgery. Discussion: Incidence of colon perforation is common with therapeutic, as compared to diagnostic, colonoscopy. Subdiaphragmatic free air suggest intraperitoneal perforation, whereas subcutaneous emphysema, pneumoretroperitoneum, and pneumomediatinum suggest extraperitoneal perforation. Extraperitoneal perforation without peritoneal signs can be treated conservatively with bowel rest and antibiotics. Microperforation usually close with omental adherence, and symptoms resolve within 24-48 hours.Figure: CT Chest showing pneumomediastinum.