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DOI: 10.1055/s-2008-1077366
© Georg Thieme Verlag KG Stuttgart · New York
Post-colonoscopy tension pneumothorax resulting from colonic barotrauma in a previously unrecognised left-sided diaphragmatic hernia
E. B. Alabraba, MD
Liver Research Group
Medical School, University of Birmingham
Birmingham B15 2TT
UK
Fax: + 44-121-41-58701
Email: e.b.alabraba@bham.ac.uk
Publication History
Publication Date:
16 July 2008 (online)
When unexpected diaphragmatic hernias result in colonic perforation during colonoscopy, they are always associated with pneumothorax and are always fatal [1] [2]. We report a case of colonoscopy-induced tension pneumothorax due to an undiagnosed diaphragmatic hernia without colonic perforation.
A 46-year-old man with no history of thoracoabdominal trauma underwent colonoscopy for rectal bleeding. Colonoscopic progress though initially straightforward became difficult beyond the splenic flexure. The procedure was abandoned due to abdominal discomfort. The patient was discharged after a satisfactory post-procedural examination. After 6 hours he presented with chest pain and breathlessness due to a left-sided tension pneumothorax ([Fig. 1]). Following decompression and chest drain insertion, he was managed in the intensive therapy unit. The left lung failed to re-expand due to a left-sided diaphragmatic hernia ([Fig. 2]) that was later repaired by open surgery. The hernia contained an incarcerated colonic loop that was resected with primary colonic anastomosis followed by closure of the hernial defect. Histological examination of the specimen ([Fig. 3]) suggested ischemic damage but not perforation. The lung re-expanded after 4 days and the patient was discharged shortly afterwards. Radiological evidence suggested the hernia was probably of traumatic origin.
Late diagnosis of traumatic hernias impedes their management, with unexpected diagnoses after a latency period [3] [4] or at post-mortem [5]. The abdomen-to-thorax pressure gradient favors progressive herniation of viscera through undiagnosed diaphragmatic defects. The lack of supporting evidence (radiological or histological) and the nonfatal outcome meant that it was unlikely colonic perforation had occurred. The hernia contained a colonic loop, causing acute angulation and impeding the passage of the colonoscope. We are convinced that the pneumothorax resulted from the avulsion of adherent lung away from the incarcerated colonic segment ([Fig. 4]). Maneuvering of the instrument and stretching of the colonic segment on air-insufflation caused avulsion of adherent colon, creating a defect in the apposed lung surface along with rupture of associated alveoli. Good postprocedural advice, excellent emergency medical management and sound surgical repair ensured that the patient had a good outcome.
Endoscopy_UCTN_Code_CPL_1AJ_2AC
#References
- 1 Chae H S, Kim S S, Han S W. et al . Herniation of the large bowel through a posttraumatic diaphragmatic defect during colonoscopy: report of a case. Dis Colon Rectum. 2002; 45 1261-1262
- 2 Baumann U A, Mettler M. Diagnosis and hazards of unexpected diaphragmatic hernias during colonoscopy: report of two cases. Endoscopy. 1999; 31 274-276
- 3 Ahmad J, Beattie G C, Kennedy R. et al . Penetrating trauma to the junctional zone needs aggressive management. BMJ. 2007; 334 257-258
- 4 Ball T, McCrory R, Smith J O, Clements Jr J L. Traumatic diaphragmatic hernia: errors in diagnosis. AJR Am J Roentgenol. 1982; 138 633-637
- 5 Christophi C. Diagnosis of traumatic diaphragmatic hernia: analysis of 63 cases. World J Surg. 1983; 7 277-280
E. B. Alabraba, MD
Liver Research Group
Medical School, University of Birmingham
Birmingham B15 2TT
UK
Fax: + 44-121-41-58701
Email: e.b.alabraba@bham.ac.uk
References
- 1 Chae H S, Kim S S, Han S W. et al . Herniation of the large bowel through a posttraumatic diaphragmatic defect during colonoscopy: report of a case. Dis Colon Rectum. 2002; 45 1261-1262
- 2 Baumann U A, Mettler M. Diagnosis and hazards of unexpected diaphragmatic hernias during colonoscopy: report of two cases. Endoscopy. 1999; 31 274-276
- 3 Ahmad J, Beattie G C, Kennedy R. et al . Penetrating trauma to the junctional zone needs aggressive management. BMJ. 2007; 334 257-258
- 4 Ball T, McCrory R, Smith J O, Clements Jr J L. Traumatic diaphragmatic hernia: errors in diagnosis. AJR Am J Roentgenol. 1982; 138 633-637
- 5 Christophi C. Diagnosis of traumatic diaphragmatic hernia: analysis of 63 cases. World J Surg. 1983; 7 277-280
E. B. Alabraba, MD
Liver Research Group
Medical School, University of Birmingham
Birmingham B15 2TT
UK
Fax: + 44-121-41-58701
Email: e.b.alabraba@bham.ac.uk