DFIB Posted October 12, 2012 Posted October 12, 2012 Could air have tracked the esophagus through the esophageal hiatus. I am unclear of the exact mechanism.
paramedicmike Posted October 12, 2012 Posted October 12, 2012 I have a couple ideas. Without knowing for sure where the colon was perforated there are sections of the colon (ascending, descending and rectum) that are retroperitoneally located. With a section of the colon perforated in one of these retroperitoneal spaces the CO2 from the procedure could travel along the retroperitoneal space, into the subcutaneous tissue and then up towards the neck. From what I'm reading, however, retroperitoneal perforations of the colon during a colonoscopy are rare. My other idea has to do with CO2 passage from the retroperitoneal space along the vessels through the diaphragmatic hiatus into the mediastinum. What gets me with this idea is that you said there's no pneumomediastinum. Is it possible for the gas to pass through this passageway into the subcutaneous tissue without causing a pneumomediastinum or pneumothorax? Still researching...
ERDoc Posted October 12, 2012 Author Posted October 12, 2012 All very good thoughts but they would lead to pneumomediastinum. Some how the air is leaving the intracavitary space and becoming subq. We know the source is in the abdomen but how is it getting from the intraabdomenal space and going subq? Looking at the pt, it starts at the level of the belly button and goes as high as the jaw. There is no subq air below the umbilicus.
Arctickat Posted October 12, 2012 Posted October 12, 2012 Hmmm, no other surgical history....specifically something that would leave a scar in the belly button and lead to pericarditis?
AnthonyM83 Posted October 13, 2012 Posted October 13, 2012 Why was the colonoscopy being done in the first place? What symptoms was he experiencing? Did he have a pre-existing wound/lesion in the perioneal space?
ERDoc Posted October 13, 2012 Author Posted October 13, 2012 It was a routine colonoscopy as the pt has a strong family history of colon cancer (and pericarditis). He does not personally have any lesions. No other surgical history so no scaring at the belly button but you are getting close.
paramedicmike Posted October 13, 2012 Posted October 13, 2012 Unless he has a lower ventral or umbilical hernia I'm coming up blank. 1
Arctickat Posted October 13, 2012 Posted October 13, 2012 (edited) He's a sword swallower and it slipped, perforating the stomach? No, no, that would just make him belch his own farts....hmmm....explains the pericarditis though. Edited October 13, 2012 by Arctickat
ERDoc Posted October 14, 2012 Author Posted October 14, 2012 Unless he has a lower ventral or umbilical hernia I'm coming up blank. Awesome job Mike. This is a great case of thinking about normal and abnormal anatomy. You had to think outside the box to figure it out. Luckily I had the CT scan so I didn't have to. The guy had an umbilical hernia and the free air was slipping out through the small defect in the abd wall and tracking up. Mike gets my nomination for provider of the year and Arctic gets runner up for keeping his differential consistently broad. 1
paramedicmike Posted October 14, 2012 Posted October 14, 2012 No way! That's awesome. Thanks for an excellent case study. 1
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