[Retroperitoneal, mediastinal and subcutaneous emphysema with pneumothorax after colonoscopy]

Severe ulcerative colitis had been diagnosed in a 25-year-old man six years ago. That same year he underwent laparoscopy for mechanical ileus. Since then he has been on a maintenance dose of sulphasalazine without any further symptoms. Because of a known pseudopolyposis coli, repeat coloscopy was performed. EXAMINATIONS AND FINDINGS: The endoscope was smoothly introduced and the examination was without pain. No premedication had been given. A biopsy was obtained during withdrawal of the endoscope. Suddenly the patient noticed marked scrotal swelling. The examination was terminated abruptly. No lesions of the wall of the distal colon were seen when the endoscope was pulled out immediately. Quickly, cutaneous emphysema developed over the right side of the abdomen and thorax up to the neck. The patient could no more properly hear his own voice. Radiology demonstrated bilateral pneumoretroperitoneum, mediastinal emphysema and pneumothorax.

The patient was put on parenteral nutrition for 4 days and prophylactically received amoxycillin, calvulanic acid and metronidazole. The air was gradually absorbed and the patient discharged symptom-free after 7 days.

In contrast to intraperitoneal perforation, which usually causes acute symptoms of peritonitis and requires urgent surgical treatment, the course of the much rarer retroperitoneal perforation is more benign with few symptoms and can be managed conservatively.