CC BY 4.0 · Surg J (N Y) 2018; 04(01): e7-e13
DOI: 10.1055/s-0038-1624563
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Anatomical and Radiological Considerations When Colonic Perforation Leads to Subcutaneous Emphysema, Pneumothoraces, Pneumomediastinum, and Mediastinal Shift

Sala Abdalla
1   Departments of General Surgery and Radiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
Rupinder Gill
1   Departments of General Surgery and Radiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
Gibran Timothy Yusuf
1   Departments of General Surgery and Radiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
Rosaria Scarpinata
1   Departments of General Surgery and Radiology, King's College Hospital NHS Foundation Trust, London, United Kingdom
› Author Affiliations
Further Information

Publication History

22 September 2017

18 December 2017

Publication Date:
22 February 2018 (online)


While colonoscopy is generally regarded as a safe procedure, colonic perforation can occur and the risk of this is higher when interventional procedures are undertaken. The presentation may be acute or delayed depending on the extent of the perforation. Extracolonic gas following colonic perforation can migrate to several body compartments that are embryologically related and it has previously been reported in the thorax, mediastinum, neck, scrotum, and lower limbs. This review discusses in detail the anatomical pathways that led to a rare case of widespread subcutaneous emphysema, bilateral pneumothoraces, pneumomediastinum, and mediastinal shift from colonic perforation during a diagnostic colonoscopy. This is further supported by a description of the radiological images.

  • References

  • 1 The NHS Atlas of variation. Rate of colonoscopy procedures and flexisigmoidoscopy procedures per population per PCT. 2011 Atlas_2011_CancerMaps.pdf. . Accessed February 15, 2018
  • 2 Lohsiriwat V. Colonoscopic perforation: incidence, risk factors, management and outcome. World J Gastroenterol 2010; 16 (04) 425-430
  • 3 Waye JD. Colonoscopy. CA Cancer J Clin 1992; 42 (06) 350-365
  • 4 Ho HC, Burchell S, Morris P, Yu M. Colon perforation, bilateral pneumothoraces, pneumopericardium, pneumomediastinum, and subcutaneous emphysema complicating endoscopic polypectomy: anatomic and management considerations. Am Surg 1996; 62 (09) 770-774
  • 5 Ignjatović M, Jović J. Tension pneumothorax, pneumoretroperitoneum, and subcutaneous emphysema after colonoscopic polypectomy: a case report and review of the literature. Langenbecks Arch Surg 2009; 394 (01) 185-189
  • 6 Kipple JC. Bilateral tension pneumothoraces and subcutaneous emphysema following colonoscopic polypectomy: a case report and discussion of anesthesia considerations. AANA J 2010; 78 (06) 462-467
  • 7 Marwan K, Farmer KC, Varley C, Chapple KS. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema following diagnostic colonoscopy. Ann R Coll Surg Engl 2007; 89 (05) W20-1
  • 8 Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984; 144 (07) 1447-1453
  • 9 Webb T. Pneumothorax and pneumomediastinum during colonoscopy. Anaesth Intensive Care 1998; 26 (03) 302-304
  • 10 Zeno BR, Sahn SA. Colonoscopy-associated pneumothorax: a case of tension pneumothorax and review of the literature. Am J Med Sci 2006; 332 (03) 153-155
  • 11 Bakker J, van Kersen F, Bellaar Spruyt J. Pneumopericardium and pneumomediastinum after polypectomy. Endoscopy 1991; 23 (01) 46-47
  • 12 Damore II LJ, Rantis PC, Vernava III AM, Longo WE. Colonoscopic perforations. Etiology, diagnosis, and management. Dis Colon Rectum 1996; 39 (11) 1308-1314
  • 13 Anderson ML, Pasha TM, Leighton JA. Endoscopic perforation of the colon: lessons from a 10-year study. Am J Gastroenterol 2000; 95 (12) 3418-3422
  • 14 Panteris V, Haringsma J, Kuipers EJ. Colonoscopy perforation rate, mechanisms and outcome: from diagnostic to therapeutic colonoscopy. Endoscopy 2009; 41 (11) 941-951
  • 15 Hamdani U, Naeem R, Haider F. , et al. Risk factors for colonoscopic perforation: a population-based study of 80118 cases. World J Gastroenterol 2013; 19 (23) 3596-3601
  • 16 Hall-Craggs ECB. Anatomy As a Basis for Clinical Medicine. London: Williams and Wilkins; 1995: 176-177 , 241–243
  • 17 Lumley JSP, Craven JL, Aitken JT. Essential Anatomy. London: Churchill Livingstone; 1987. :77, 115-117
  • 18 Lidid L, Valenzuela J, Villarroel C, Alegria J. Crossing the barrier: when the diaphragm is not a limit. AJR Am J Roentgenol 2013; 200 (01) W62-70
  • 19 Frias Vilaça A, Reis AM, Vidal IM. The anatomical compartments and their connections as demonstrated by ectopic air. Insights Imaging 2013; 4 (06) 759-772
  • 20 Giambattista Morgagni. De sedibus, et causis morborum per anatomen indagatis libri quinque. Venice: Typographia Remondini; 1761
  • 21 Alabraba E, Gourevitch D, Hejmadi R, Ismail T, Cockel R. Post-colonoscopy tension pneumothorax resulting from colonic barotrauma in a previously unrecognised left-sided diaphragmatic hernia. Endoscopy 2008; 40 (02) (Suppl. 02) E128-E129
  • 22 Lovisetto F, Zonta S, Rota E. , et al. Left pneumothorax secondary to colonoscopic perforation of the sigmoid colon: a case report. Surg Laparosc Endosc Percutan Tech 2007; 17 (01) 62-64
  • 23 Panicek DM, Benson CB, Gottlieb RH, Heitzman ER. The diaphragm: anatomic, pathologic, and radiologic considerations. Radiographics 1988; 8 (03) 385-425
  • 24 Sugarbaker DJ, Bueno R, Krasna M, Mentzer SJ, Zellos L. Adult Chest Surgery. New York: McGraw Hill; 2009: 50-54