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Diffuse Subcutaneous Air due to Rectal Perforation

Wang, Yong MD1; Wu, Xiao-Ting MD, FACS1

doi: 10.14309/crj.0000000000000128

1Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China

Correspondence: Xiao-Ting Wu, MD, FACS, Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, 37 Guo Xue Rd, Chengdu 610041, Sichuan Province, China (

Received December 05, 2018

Accepted April 08, 2019

Online date: June 25, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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A 75-year-old woman with diabetes mellitus and myocardial ischemia underwent colonoscopic polypectomy for a single colon polyp in 2016. Postoperative diagnosis showed colonic adenoma. She previously underwent a colonoscopy at a local hospital to determine the cause of diarrhea; nothing was observed during this colonoscopy. After that colonoscopy, she reported abdominal discomfort and profound abdominal distention gradually developed with nausea and vomiting. Diffuse subcutaneous air subsequently accumulated over cervical, thoracic, and abdominal wall. She refused to continue the treatment in that hospital and asked to transfer to another hospital for treatment.

On admission to our hospital, abdominal palpation revealed abdominal muscle tension, tenderness, and rebound pain, with white blood count of 14.84 × 109/L. Computed tomography showed extensive gas accumulation subcutaneously in the neck and thorax and in the abdominal wall, mediastinum, thoracic cavity, abdominal cavity, and retroperitoneum (Figure 1). The patient underwent emergency surgery, during which we found that the superior mesenteral margin of the rectum was perforated and the small mesenteric membrane showed gas accumulation (Figure 2). Surgery to repair the sigmoid colon and rectum was performed, after which the subcutaneous gas accumulation gradually subsided, and she was discharged after recovery.

Figure 1

Figure 1

Figure 2

Figure 2

Some patients with perforation after colonoscopy may be admitted, given antibiotic agents, and will recover fully without additional intervention. Others, especially stable patients without comorbidities, may require surgery to repair the perforation. Our patient was admitted to our hospital more than 10 hours after colonoscopy with signs of peritonitis. Thus, antibiotic agents and repairing surgery were not suitable for this patient. For the elderly, we advise that colonoscopy should be performed with gentle and appropriate inflatable pressure. Early diagnosis and treatment of perforation should be pursued by close monitoring after the examination.

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Author contributions: Both authors contributed equally to the writing and editing of the manuscript. X-T Wu is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

© 2019 by Lippincott Williams & Wilkins, Inc.