- Email: [email protected]
Subcutaneous Emphysema In Advanced Cancer
Vol. 19 No. 1 January 2000
Journal of Pain and Symptom Management 73
Clinical Note
Subcutaneous Emphysema In Advanced Cancer Simon Chu, MBBS DCH and Paul Glare, MBBS FRACP Department of Medical Oncology and Palliative Care, Westmead Hospital, Westmead, New South Wales, Australia
Abstract Spontaneous subcutaneous emphysema is a rare and usually benign entity that may occasionally be symptomatic. We report a case of a patient with advanced cancer who developed extensive but asymptomatic subcutaneous emphysema shortly before death. Perforation of the lower gastrointestinal tract, perhaps as a result of straining due to severe unrelieved constipation or due to fistula formation, is suspected to have been the mechanism. The causes, treatment, and implications for management of this condition are discussed. J. Pain Symptom Manage 2000; 19:73–77. © U.S. Cancer Pain Relief Committee, 2000. Key Words Subcutaneous emphysema, palliative care, cancer, constipation
Introduction Subcutaneous emphysema is defined as air or gas in the subcutaneous tissues.1 Gas in this fascial plane is abnormal, but usually benign, and resolves with conservative management. There are many causes of subcutaneous emphysema, all of which involve either the production of gas in that plane, (e.g., gas gangrene), or the presence of a communication between this fascial plane and a structure normally in contact with air (e.g., after a penetrating wound).1,2 Despite its many possible causes, subcutaneous emphysema is an infrequent clinical finding.
Case History A 54-year-old woman with advanced colon cancer presented to the emergency depart-
Address reprint requests to: Simon Chu, MB BS, Emergency Department, St. George Hospital, Gray St., Kogarah, New South Wales, Australia. Accepted for publication: March 1, 1999 © U.S. Cancer Pain Relief Committee, 2000 Published by Elsevier, New York, New York
ment of a metropolitan university teaching hospital with abdominal pain, constipation, and lethargy. She had been found to have a Dukes C adenocarcinoma of the transverse colon, involving five mesenteric lymph nodes, 12 months earlier and had undergone a transverse colectomy followed by adjuvant chemotherapy. The chemotherapy consisted of 15 cycles of 5-fluorouracil (5-FU) and levamisole, administered over the following 7 months via Portacath catheter inserted in the right subclavian vein. Treatment was stopped when she presented with bowel obstruction, and an exploratory laparotomy revealed a local recurrence of the primary tumor with metastases to the pelvis, liver, and peritoneum. Despite a surgical bypass, she continued to vomit, presumably due to the liver metastases. This symptom was eventually controlled with haloperidol. The week before presenting to the emergency department, the patient became increasingly lethargic and weak. Three days before presentation, she fell at home striking the Portacath insertion site against the edge of the bathtub. At presentation, she had not defe0885-3924/00/$–see front matter PII S0885-3924(99)00136-0
74
Chu and Glare
Vol. 19 No. 1 January 2000
Fig. 1. CXR of patient with subcutaneous emphysema.
cated for 7 days, despite straining hard, and complained of sharp, constant pain around the abdominal surgical scar. Her medications at that time were controlled-release oral morphine 50 mg twice daily, haloperidol, and dexamethasone. On examination, she was drowsy, but hemodynamically stable. She had a distended abdomen with tenderness around the scar, but no peritoneal signs. She had a significant nontender hematoma over the site of her Portacath, and subcutaneous crepitus was found at the base of her back and extending over all the trunk and to the elbows and thighs. The rest of the physical examination was unremarkable. Laboratory investigations were normal apart from mildly abnormal liver function tests consistent with her known liver metastases. On abdominal and chest radiographs (see Figures 1 and 2), the most striking feature was extensive subcutaneous emphysema. No pneumomediastinum or pneumothorax was present. The patient later had a computerized tomography (CT) scan of her head, neck, and chest (see
Figure 3). The cerebral CT scan showed no cerebral metastases. The neck and chest CT showed extensive subcutaneous emphysema, up to 3 cm in depth between the subcutaneous tissues, and a small pneumomediastinum, but no pneumothorax. No cause of the emphysema could be found. A sigmoidoscopy was planned, but the patient died before this could be done. A postmortem examination was not permitted by the family.
Discussion Nontraumatic subcutaneous emphysema is rare in cancer patients.3 In this patient, a number of etiologies were possible, but the lower gastrointestinal tract (GIT) is the most likely site of communication between an air-filled organ and the subcutaneous tissues. There was no reason to suspect infection with a gas-forming organism. There have been several reports of lower GIT perforation causing subcutaneous emphysema, including iatrogenic and pathological causes.4,5
Vol. 19 No. 1 January 2000
Subcutaneous Emphysema in Advanced Cancer
75
Fig. 2. AXR of patient.
The patient had not defecated for 7 days, despite straining. Prolonged straining can produce anorectal fissure, which in turn can cause subcutaneous emphysema,6 and this condition has also been reported in women straining during labor.7 The various consequences of unrelieved constipation in cancer patients are well recognized.8,9 The patient also had known local recurrence of the tumor at the site of anastomosis from her previous operation, which could also be the source, as a perforated esophageal carcinoma has recently been reported to cause extensive subcutaneous emphysema.10 Nonmalignant esophageal perforation is another important cause of subcutaneous emphysema (Boerhaave’s syndrome). It involves perforation secondary to violent vomiting, and results in subcutaneous emphysema.11,12 However, the typical triad of vomiting, chest pain, and subcutaneous emphysema11 was not present in this pa-
tient. Although the CT scan revealed a pneumomediastinum (an important feature of Boerhaave’s syndrome), an esophageal perforation could not be identified. Another cause is through communication between the respiratory system and the subcutaneous fascial layer. Endodontic treatment is known to cause cervical emphysema,13 but this patient’s dentition was normal, and there was no evidence of facial bone fracture from her fall prior to admission. Any disruption of the bronchial tree can be a source of air. Blunt trauma of the neck can lead to laryngotracheal disruption,14 and laryngocoeles can spontaneously rupture. The CT scan in this patient excluded the presence of a laryngocoele. Rib fractures can lead to subcutaneous emphysema, usually associated with a pneumothorax. It was thought in this case that the patient’s fall may have placed force on her Portacath and fractured a rib, as evidenced by the large hematoma
76
Chu and Glare
Vol. 19 No. 1 January 2000
Fig. 3.
in the Portacath region. However, she had little pain locally and rib fracture has not been reported as a complication of Portacath usage.15 As the patient did not complain of chest pain or shortness of breath, the decision was made to treat conservatively, and to attempt to discover and treat a cause for the subcutaneous emphysema in due course. For symptomatic subcutaneous emphysema, treatment involves insertion of a large bore drain.16 As an autopsy was not performed, the cause of the subcutaneous emphysema is uncertain. Because it was asymptomatic, we do not believe it contributed directly to her death. The implications of subcutaneous emphysema for palliative care include the distress associated with symptomatic tension emphysema, and the unavailability of the transdermal and subcutaneous routes for drug administration. The presence of air in the subcutis makes the absorption and bioavailability of medications unpredictable via these routes, and intravenous or intramuscular routes would have to be used if parenteral administration were required.
In conclusion, we report a case of a patient with advanced cancer presenting with the unusual clinical finding of extensive subcutaneous emphysema. The precise cause could not be determined before death and an autopsy was not carried out. Subcutaneous emphysema may produce distressing symptoms if severe, although it did not in this case. Its presence interferes with administration of medications by the subcutaneous and transdermal route. If distressing enough, the release of the air via a subcutaneous drain may be indicated. If it is not causing distress to the patient, it is usually appropriate to observe the patient until the air resorbs back into the body.
References 1. Doweiko JP, Alter C. Subcutaneous emphysema: report or a case and review of the literature. Dermatology 1992;184:62–64. 2. Lau KY. Pneumomediastinum caused by subcutaneous emphysema in the shoulder: a rare complication of arthroscopy. Chest 1993;103:1606–1607.
Vol. 19 No. 1 January 2000
Subcutaneous Emphysema in Advanced Cancer
77
3. Chow E, Wong CS, Goldberg RE, Stern HS. Nontraumatic subcutaneous emphysema in association with rectal carcinoma. Can Assoc Radiol J 1996; 47:94–97.
10. Jager GJ, Joosten F, Van der Berkmortel FW, Saleshas JM. Subcutaneous emphysema of the lower extremity secondary to a perforated esophageal carcinoma. Abd Imaging 1995;20:23–25.
4. Savides T, Sherman S, Kadell B, Cryer H, Derezin M. Bilateral pneumothoraces and subcutaneous emphysema after endoscopic sphincterotomy. Gastrointest Endosc 1993;39:814–817.
11. White CS, Templeton PA, Altar S. Esophageal perforation: CT findings. Am J Roentgenol 1993; 160:767–770.
5. Fitzgerald SD, Denk A, Flynn M, Longo WE, Vernova AM. Pneumopericardium and subcutaneous emphysema of the neck: an unusual manifestation of colonoscopic perforation. Surg Endosc 1992; 6:141–143. 6. Brunet C, Thomas P, Sielezneff I, Ugarte S, Sastre B, Guidicelli R. Subcutaneous cervical emphysema: complication of constipation. Review of the literature. J Chir Paris 1995;132:198–200. 7. Gemer O, Popescu M, Lebowitz O, Segal S. Pneumomediastinum in labour. Arch Gynecol Obstet 1994;225:47–49.
12. Woolford TJ, Birzgalis AR, Lundell C, Farrington WT. Vomiting in pregnancy resulting in oesophageal perforation in a 15 year old. J Laryngol Otol 1993;107:1059–1060. 13. Shackelford D, Casani JA. Diffuse subcutaneous emphysema, pneumomediastinum, and pneumothorax after dental extraction. Ann Emerg Med 1993;22:248–250. 14. Ford HR, Gardner MJ, Lynch JM. Laryngotracheal disruption from blunt pediatric neck injuries: impact of early recognition and intervention on outcome. J Pediatr Surg 1995;30:331–334.
8. Potenoy RK. Constipation in the cancer patient; causes and management. Med Clin North Am 1987; 71:303–311.
15. Sariego J, Bootorabi B, Matsumoto T, Kerstein M. Major long term complications in 1,422 permanent venous access devices. Am J Surg 1993;165: 249–251.
9. Glare P, Lickiss JN. Unrecognized constipation in patients with advanced cancer: a recipe for therapeutic disaster. J Pain Symptom Manage 1992;7:1–3.
16. Kelly MC, McGuigan JA, Allen RW. Relief of tension subcutaneous emphysema using a large bore subcutaneous drain. Anaesthesia 1995;50:1077–1079.
Journal of Pain and Symptom Management 73
Clinical Note
Subcutaneous Emphysema In Advanced Cancer Simon Chu, MBBS DCH and Paul Glare, MBBS FRACP Department of Medical Oncology and Palliative Care, Westmead Hospital, Westmead, New South Wales, Australia
Abstract Spontaneous subcutaneous emphysema is a rare and usually benign entity that may occasionally be symptomatic. We report a case of a patient with advanced cancer who developed extensive but asymptomatic subcutaneous emphysema shortly before death. Perforation of the lower gastrointestinal tract, perhaps as a result of straining due to severe unrelieved constipation or due to fistula formation, is suspected to have been the mechanism. The causes, treatment, and implications for management of this condition are discussed. J. Pain Symptom Manage 2000; 19:73–77. © U.S. Cancer Pain Relief Committee, 2000. Key Words Subcutaneous emphysema, palliative care, cancer, constipation
Introduction Subcutaneous emphysema is defined as air or gas in the subcutaneous tissues.1 Gas in this fascial plane is abnormal, but usually benign, and resolves with conservative management. There are many causes of subcutaneous emphysema, all of which involve either the production of gas in that plane, (e.g., gas gangrene), or the presence of a communication between this fascial plane and a structure normally in contact with air (e.g., after a penetrating wound).1,2 Despite its many possible causes, subcutaneous emphysema is an infrequent clinical finding.
Case History A 54-year-old woman with advanced colon cancer presented to the emergency depart-
Address reprint requests to: Simon Chu, MB BS, Emergency Department, St. George Hospital, Gray St., Kogarah, New South Wales, Australia. Accepted for publication: March 1, 1999 © U.S. Cancer Pain Relief Committee, 2000 Published by Elsevier, New York, New York
ment of a metropolitan university teaching hospital with abdominal pain, constipation, and lethargy. She had been found to have a Dukes C adenocarcinoma of the transverse colon, involving five mesenteric lymph nodes, 12 months earlier and had undergone a transverse colectomy followed by adjuvant chemotherapy. The chemotherapy consisted of 15 cycles of 5-fluorouracil (5-FU) and levamisole, administered over the following 7 months via Portacath catheter inserted in the right subclavian vein. Treatment was stopped when she presented with bowel obstruction, and an exploratory laparotomy revealed a local recurrence of the primary tumor with metastases to the pelvis, liver, and peritoneum. Despite a surgical bypass, she continued to vomit, presumably due to the liver metastases. This symptom was eventually controlled with haloperidol. The week before presenting to the emergency department, the patient became increasingly lethargic and weak. Three days before presentation, she fell at home striking the Portacath insertion site against the edge of the bathtub. At presentation, she had not defe0885-3924/00/$–see front matter PII S0885-3924(99)00136-0
74
Chu and Glare
Vol. 19 No. 1 January 2000
Fig. 1. CXR of patient with subcutaneous emphysema.
cated for 7 days, despite straining hard, and complained of sharp, constant pain around the abdominal surgical scar. Her medications at that time were controlled-release oral morphine 50 mg twice daily, haloperidol, and dexamethasone. On examination, she was drowsy, but hemodynamically stable. She had a distended abdomen with tenderness around the scar, but no peritoneal signs. She had a significant nontender hematoma over the site of her Portacath, and subcutaneous crepitus was found at the base of her back and extending over all the trunk and to the elbows and thighs. The rest of the physical examination was unremarkable. Laboratory investigations were normal apart from mildly abnormal liver function tests consistent with her known liver metastases. On abdominal and chest radiographs (see Figures 1 and 2), the most striking feature was extensive subcutaneous emphysema. No pneumomediastinum or pneumothorax was present. The patient later had a computerized tomography (CT) scan of her head, neck, and chest (see
Figure 3). The cerebral CT scan showed no cerebral metastases. The neck and chest CT showed extensive subcutaneous emphysema, up to 3 cm in depth between the subcutaneous tissues, and a small pneumomediastinum, but no pneumothorax. No cause of the emphysema could be found. A sigmoidoscopy was planned, but the patient died before this could be done. A postmortem examination was not permitted by the family.
Discussion Nontraumatic subcutaneous emphysema is rare in cancer patients.3 In this patient, a number of etiologies were possible, but the lower gastrointestinal tract (GIT) is the most likely site of communication between an air-filled organ and the subcutaneous tissues. There was no reason to suspect infection with a gas-forming organism. There have been several reports of lower GIT perforation causing subcutaneous emphysema, including iatrogenic and pathological causes.4,5
Vol. 19 No. 1 January 2000
Subcutaneous Emphysema in Advanced Cancer
75
Fig. 2. AXR of patient.
The patient had not defecated for 7 days, despite straining. Prolonged straining can produce anorectal fissure, which in turn can cause subcutaneous emphysema,6 and this condition has also been reported in women straining during labor.7 The various consequences of unrelieved constipation in cancer patients are well recognized.8,9 The patient also had known local recurrence of the tumor at the site of anastomosis from her previous operation, which could also be the source, as a perforated esophageal carcinoma has recently been reported to cause extensive subcutaneous emphysema.10 Nonmalignant esophageal perforation is another important cause of subcutaneous emphysema (Boerhaave’s syndrome). It involves perforation secondary to violent vomiting, and results in subcutaneous emphysema.11,12 However, the typical triad of vomiting, chest pain, and subcutaneous emphysema11 was not present in this pa-
tient. Although the CT scan revealed a pneumomediastinum (an important feature of Boerhaave’s syndrome), an esophageal perforation could not be identified. Another cause is through communication between the respiratory system and the subcutaneous fascial layer. Endodontic treatment is known to cause cervical emphysema,13 but this patient’s dentition was normal, and there was no evidence of facial bone fracture from her fall prior to admission. Any disruption of the bronchial tree can be a source of air. Blunt trauma of the neck can lead to laryngotracheal disruption,14 and laryngocoeles can spontaneously rupture. The CT scan in this patient excluded the presence of a laryngocoele. Rib fractures can lead to subcutaneous emphysema, usually associated with a pneumothorax. It was thought in this case that the patient’s fall may have placed force on her Portacath and fractured a rib, as evidenced by the large hematoma
76
Chu and Glare
Vol. 19 No. 1 January 2000
Fig. 3.
in the Portacath region. However, she had little pain locally and rib fracture has not been reported as a complication of Portacath usage.15 As the patient did not complain of chest pain or shortness of breath, the decision was made to treat conservatively, and to attempt to discover and treat a cause for the subcutaneous emphysema in due course. For symptomatic subcutaneous emphysema, treatment involves insertion of a large bore drain.16 As an autopsy was not performed, the cause of the subcutaneous emphysema is uncertain. Because it was asymptomatic, we do not believe it contributed directly to her death. The implications of subcutaneous emphysema for palliative care include the distress associated with symptomatic tension emphysema, and the unavailability of the transdermal and subcutaneous routes for drug administration. The presence of air in the subcutis makes the absorption and bioavailability of medications unpredictable via these routes, and intravenous or intramuscular routes would have to be used if parenteral administration were required.
In conclusion, we report a case of a patient with advanced cancer presenting with the unusual clinical finding of extensive subcutaneous emphysema. The precise cause could not be determined before death and an autopsy was not carried out. Subcutaneous emphysema may produce distressing symptoms if severe, although it did not in this case. Its presence interferes with administration of medications by the subcutaneous and transdermal route. If distressing enough, the release of the air via a subcutaneous drain may be indicated. If it is not causing distress to the patient, it is usually appropriate to observe the patient until the air resorbs back into the body.
References 1. Doweiko JP, Alter C. Subcutaneous emphysema: report or a case and review of the literature. Dermatology 1992;184:62–64. 2. Lau KY. Pneumomediastinum caused by subcutaneous emphysema in the shoulder: a rare complication of arthroscopy. Chest 1993;103:1606–1607.
Vol. 19 No. 1 January 2000
Subcutaneous Emphysema in Advanced Cancer
77
3. Chow E, Wong CS, Goldberg RE, Stern HS. Nontraumatic subcutaneous emphysema in association with rectal carcinoma. Can Assoc Radiol J 1996; 47:94–97.
10. Jager GJ, Joosten F, Van der Berkmortel FW, Saleshas JM. Subcutaneous emphysema of the lower extremity secondary to a perforated esophageal carcinoma. Abd Imaging 1995;20:23–25.
4. Savides T, Sherman S, Kadell B, Cryer H, Derezin M. Bilateral pneumothoraces and subcutaneous emphysema after endoscopic sphincterotomy. Gastrointest Endosc 1993;39:814–817.
11. White CS, Templeton PA, Altar S. Esophageal perforation: CT findings. Am J Roentgenol 1993; 160:767–770.
5. Fitzgerald SD, Denk A, Flynn M, Longo WE, Vernova AM. Pneumopericardium and subcutaneous emphysema of the neck: an unusual manifestation of colonoscopic perforation. Surg Endosc 1992; 6:141–143. 6. Brunet C, Thomas P, Sielezneff I, Ugarte S, Sastre B, Guidicelli R. Subcutaneous cervical emphysema: complication of constipation. Review of the literature. J Chir Paris 1995;132:198–200. 7. Gemer O, Popescu M, Lebowitz O, Segal S. Pneumomediastinum in labour. Arch Gynecol Obstet 1994;225:47–49.
12. Woolford TJ, Birzgalis AR, Lundell C, Farrington WT. Vomiting in pregnancy resulting in oesophageal perforation in a 15 year old. J Laryngol Otol 1993;107:1059–1060. 13. Shackelford D, Casani JA. Diffuse subcutaneous emphysema, pneumomediastinum, and pneumothorax after dental extraction. Ann Emerg Med 1993;22:248–250. 14. Ford HR, Gardner MJ, Lynch JM. Laryngotracheal disruption from blunt pediatric neck injuries: impact of early recognition and intervention on outcome. J Pediatr Surg 1995;30:331–334.
8. Potenoy RK. Constipation in the cancer patient; causes and management. Med Clin North Am 1987; 71:303–311.
15. Sariego J, Bootorabi B, Matsumoto T, Kerstein M. Major long term complications in 1,422 permanent venous access devices. Am J Surg 1993;165: 249–251.
9. Glare P, Lickiss JN. Unrecognized constipation in patients with advanced cancer: a recipe for therapeutic disaster. J Pain Symptom Manage 1992;7:1–3.
16. Kelly MC, McGuigan JA, Allen RW. Relief of tension subcutaneous emphysema using a large bore subcutaneous drain. Anaesthesia 1995;50:1077–1079.