Cervical emphysema caused by Colonic perforation – A Case report

A 65-year-old woman presents to the emergency department due to diffuse abdominal pain, constipation during the last week, and vomiting for the last 12 hours.

Her relevant past medical history includes colon diverticulosis identified on a colonoscopy performed 5 years before. She had no history of abdominal surgery.

The patient was hemodynamically stable and had no respiratory complaints. Physical examination showed crepitation in the chest wall, a distended abdomen with pain in the left quadrants and signs of peritoneal irritation.

Blood samples showed elevated inflammatory markers.

The chest (figure 1) and abdominal (figure 2) radiographs performed in the emergency department showed right cervical emphysema (arrow in figure 1) but no evidence of pneumoperitoneum.

CT was performed to further clarify the diagnosis, showing subcutaneous emphysema in the cervical region and chest wall (figure 3 and 6) and pneumomediastinum (figure 4 and 6). In the abdomen, CT showed extra-luminal feces associated with voluminous retropneumoperitoneum and a very small pneumoperitoneum (figure 6).

The patient underwent emergency laparotomy, where fecaloid peritonitis, sigmoid colon necrosis and perforation on the posterior wall were found. No palpable masses or significant diverticula were identified. A Hartmann procedure was performed.

Surgery was complicated by an intra-abdominal abscess, which was treated with percutaneous drainage and antibiotics.

The patient was discharged 20 days after the surgery. Histology did not show signs of inflammation or malignancy.