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Tension pneumoperitoneum following colonic perforation due to barotrauma
  1. Rashmi Vijaya Kumar,
  2. Oseen Hajilal Shaikh,
  3. Chellappa Vijayakumar and
  4. Uday Shamrao Kumbhar
  1. Surgery, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, Tamil Nadu, India
  1. Correspondence to Professor Uday Shamrao Kumbhar; k26uday74{at}yahoo.co.in

Abstract

Barotrauma of the colorectum is an uncommon entity that usually occurs after colonoscopy. Perforation of the colon by non-iatrogenic barotrauma of the colon, with tension pneumoperitoneum, is very rare. We present a case of a male patient in his 20s with colon barotrauma caused by industrial compressed air, causing perforation of the transverse colon, with multiple serosal tears throughout the colon. There was also evidence of contusion in the caecum and ascending colon. Primary repair of the perforation and repair of the serosal tears were done along with a covering loop ileostomy.

  • General surgery
  • Gastrointestinal surgery
  • Surgery

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Background

Colon barotraumas are colon injuries caused by elevated intraluminal pressures.1 They include colon mucosal traumas and colon perforation. Air insufflation during colonoscopy procedures is the most common cause of iatrogenic colon barotraumas. ‘Cat scratch’ colon occurs in a mild type of colon barotrauma and colon perforation in the severe one. In some cases, it was reported that compressed air caused colon perforation. Clinical features vary from vague symptoms to features of perforation peritonitis and usually depend on the extent of the injury.2 There may also be tension pneumoperitoneum. Radiological investigations help in confirming the diagnosis. Treatment is usually by surgical intervention and depends on the extent of the injury. We report a case of colon barotrauma presenting with tension pneumoperitoneum, intraoperatively found to have a transverse colon perforation.

Case presentation

A man in his 20s accidentally sat on the air vent of an air compressor chamber resulting in insufflation of air per rectum. Following this, the patient complained to his colleagues of severe abdominal pain. He had no complaints of vomiting. The patient was brought to the hospital within 6 hours of the injury. On presentation, his pulse rate was 108 beats per minute, blood pressure was 130/90 mm Hg, oxygen saturation was 98% on room air and respiratory rate was 24 breaths per minute. The abdomen was severely distended, tender and rigid to palpate. There was a resonant note through the abdomen on percussion. Per rectal examination, the sphincter tone was lax and the rectum was roomy, with minimal fresh blood staining. Abdominal X-ray showed tension pneumoperitoneum, with abdominal contents pushed to the midline. Chest X-ray was normal, without any pneumothorax or pneumomediastinum (figure 1).

Figure 1

X-ray of the abdomen and thorax showing (A) massive pneumoperitoneum (arrow) and (B) normal chest without any evidence of pneumothorax or pneumomediastinum, with gas under both domes of the diaphragm (arrow).

Contrast-enhanced CT was performed and showed massive pneumoperitoneum (figure 2). Bowel loops could not be commented on due to massive pneumoperitoneum leading to clumping of the bowel loops. There was clear evidence of perforation of the bowel.

Figure 2

CT of the thorax and abdomen showing (A) massive pneumoperitoneum (white arrow), with doubtful area of perforation in the transverse colon (yellow arrow). (B) There was no evidence of pneumothorax (red arrow).

As the patient was in distress due to severe abdominal distension as a result of the tension pneumoperitoneum, needle decompression of the pneumoperitoneum was done immediately. The patient underwent emergency laparotomy. Intraoperatively, we found a perforation of size 3 cm × 2 cm near the mesenteric border of the mid-transverse colon. Multiple serosal tears and contusions were present over the caecum and the ascending, transverse, descending and sigmoid colon (figure 3). The small bowel loops were normal. Primary repair of the perforation site was done in two layers. Serosal tears over the sigmoid, descending colon and transverse colon were repaired. Covering loop ileostomy was done 20 cm from the ileocaecal junction.

Figure 3

Intraoperative image showing (A) partial-thickness laceration in the sigmoid colon (arrow), (B) proximal transverse colon perforation (yellow arrow) and partial-thickness laceration in the mid-transverse colon (blue arrow), and (C) partial-thickness laceration in the caecum (yellow arrow), with a normal appendix.

Outcome and follow-up

The patient improved well postoperatively without any complications and was discharged. The ileostomy was closed after 3 months.

Discussion

Colonic barotrauma is usually iatrogenic in nature, mostly occurring during colonoscopy, with an incidence of 0.1%–0.5%.1–4 Among the colon segments, due to its large diameter, the caecum is easily affected by barotrauma. This follows Laplace’s law. The presentation can vary between mild and severe, with findings of a cat scratch colon or perforation in the severe one. McDonnell et al5 reported a case of secondary barotrauma following colonoscopy that resulted in breaks in the mucosal surface of the ascending colon. They described it as a cat scratch colon. Cat scratch colon is defined as bright erythematous linear marks resembling scratches, with an incidence of 0.25% following colonoscopy.5 The right colon and caecum are mostly subjected to injury. Cruz-Correa et al6 reported that collagenous colitis is a predisposition to a cat scratch colon.

Non-iatrogenic barotrauma to the colon is very rare. One of the causes leading to non-iatrogenic colonic barotrauma is misuse of industrial compressed air.7–10 Compressed air is used in the cleaning and fabric industries. Uninformed use of compressed air equipment may lead to rupture of the colon wall. However, colorectal injury from compressed air is not common despite its increased and widespread use in modern life. In our patient, there was an accidental entry of compressed industrial air.

Compressed air-induced barotrauma of the colon has rarely been reported in the literature. Suh et al7 reported a case of colorectal trauma in two patients. As part of a joke with their colleagues, a jet of compressed air was directed to their anus resulting in the rupture of the rectosigmoid region. One patient was managed with primary closure in two layers, and the other with primary closure in two layers with sigmoid loop colostomy.7

Coffey et al8 reported the case of a young man who sustained perineal blasting due to a compressed air hose and sustained a 3 cm perforation at the rectosigmoid junction at the taenial confluence. Tube appendostomy was done to decompress the colon and appendicectomy was subsequently done.

Choi et al11 reported a case of a man whose colleague directed the industrial air compressor towards him to cool his temperature, which resulted in multiple linear ulcers in the mucosa of the rectosigmoid colon, but with no perforation.11

In our case, compressed air caused perforation of the transverse colon with multiple serosal tears and contusions over the caecum and the ascending, transverse, descending and sigmoid colon. Misuse of compressed air leads mainly to rectosigmoid colon perforation as opposed to air insufflation during colonoscopy.7–9 Perforation occurring due to compressed air does not follow Laplace’s law. The rectosigmoid junction in the colon is the most vulnerable site due to the quickly increasing intramural pressure. The average pressure required to cause perforation of the bowel is 0.29 kg/cm2.12 Resistant strength to intraluminal pressure is maximum in the rectum, followed by the sigmoid colon, ileum, oesophagus, jejunum, transverse colon, caecum and stomach. The velocity of airflow also contributes to bowel injury. An extreme shear force is applied at the point of maximal fixation with sudden high-velocity insufflation of air. The rectosigmoid junction having bilateral fixation has limited mobility, leading to barotrauma of the rectosigmoid colon.8

The diagnosis becomes apparent when the patient presents with abdominal pain and distension after exposure to compressed air. Trauma and occupational history of using compressed air should be checked in patients with acute abdominal pain of unknown origin. If the perforation has led to the formation of the tension pneumoperitoneum, the patient may have tachypnoea, tachycardia and decreased blood pressure. Few may develop hypoxaemia and lactic acidosis.13

X-ray of the abdomen shows the presence of intraperitoneal air, which will be of high quantity. CT scan is usually done as it can locate the perforation site due to lost continuity of the bowel wall and the presence of air outside the lumen. There can be some indirect findings on CT scan, such as bowel wall thickening, inflammatory mass adjacent to the bowel, abnormal enhancement of the bowel wall and formation of abscess, which can help localise the site of perforation.14 However, the exact site of perforation may not be obvious in the acute presentation. Management of such a case depends on the severity. Immediate surgical intervention must be considered. The prognosis has generally been favourable. If the patient has tension pneumoperitoneum, needle decompression has to be done as an emergency procedure.15

The role of minimally invasive surgery is limited in such scenarios, with very few literature available. However, there is a case reported where diagnostic laparoscopy was done to identify the site of injury. They could not identify the site of injury and did intraoperative upper gastrointestinal endoscopy, which showed air emanating from the duodenum on insufflation. However, the authors performed laparotomy immediately after identification of the site of injury.16 Depending on the site and extent of injury, patients may need primary repair of the colonic injuries or resection of the colonic segment.7 Our patient underwent primary repair of the transverse colon perforation and colonic serosal tears with covering loop ileostomy.

Patient’s perspective

In an emergency to the hospital, I presented with severe abdominal pain distension after accidental air insufflation through the rectum. The treating doctors examined me, and I underwent a few imaging studies. I was informed by the doctors that my abdomen had a large amount of air, which was decompressed with needle decompression. After that, I underwent emergency surgery. I thank my doctors for emergency help.

Learning points

  • Non-iatrogenic colon barotrauma is usually caused by industrial compressed air.

  • Patients with acute abdominal pain of unknown origin should be checked for trauma and occupational history using compressed air.

  • Most cases of colon barotrauma due to compressed air reported caecal or rectosigmoid colon perforation, but other sites can also be perforated.

  • Patients who present with severe pain abdomen and distension due to tension pneumoperitoneum following barotrauma should undergo needle decompression of the abdomen followed by definitive surgical treatment.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors RVK: preparation of the manuscript. OHS: collection of data. CV: interpretation of data. USK: critical review.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.