Description

A middle-aged patient was referred for endoscopic removal of flat polyps in the ascending and descending colon. The intervention was unremarkable and during afternoon rounds the patient felt well with no abdominal pain. She did however complain of pain in the neck which she reported to have occasionally. On physical examination of the neck, a subcutaneous crepitus was noted on the right side and a CT scan was performed which revealed predominantly right-sided mediastinal and cutaneous emphysema as well as right-sided retroperitoneal but no intraperitoneal air (figures 1 and 2). Perforations after colonoscopy are rare; the most common presentation is abdominal pain and pneumoperitoneum.1 However, since parts of the ascending and descending colon are secondarily retroperitoneal, perforations may also result in pneumoretroperitoeneum, pneumomediastinum, cutaneous emphysema and even tension pneumothorax.2 Our patient’s chief complaint was moderate pain in the neck which can be the presentation of retroperitoneal perforation.3 The case was managed with parenteral antibiotics and nil per os for 2 days and the patient could be discharged after 3 days of observation with clinical resolution of both cutaneous emphysema and pain in the neck.

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Figure 1

CT scan showing predominantly right-sided mediastinal and cutaneous emphysema.

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Figure 2

CT scan showing right-sided retroperitoneal but no intraperitoneal air.