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Where is the leak?
Case Report
Where is the leak? Suresh Kumar Chhetri, Imran Aziz Lancet 2009; 373: 692 Department of Respiratory Medicine, Royal Albert Edward Infirmary, Wigan, UK (S K Chhetri MRCP, I Aziz FRCP) Correspondence to: Dr Imran Aziz, Department of Respiratory Medicine, Royal Albert Edward Infirmary, Wigan Lane, Wigan, Lancashire WN1 2NN, UK [email protected]
In March, 2007, an 84-year-old woman came to our emergency department. She had been unwell for 3 days— with a sore throat, a sense of fullness under her chin, and exertional shortness of breath. She had hypertension, osteoarthritis, and vertigo; she had had a cholecystectomy in the 1950s, and a laparotomy, for peritonitis of unrecorded cause, in her mid-teens. We found mild fever (temperature 38°C), but standard examination of the cardiovascular and respiratory systems, and the abdomen, revealed no abnormality. However, we found palpable crepitations over the neck, and in the supraclavicular fossae. Blood tests showed a high white-cell count (24∙7×10⁹ cells per L; neutrophil count 20∙4×10⁹ cells per L), ESR (67 mm/h), and concentration of C-reactive protein (254 mg/L). Tests of kidney and liver function showed no abnormality of note; A
B
the serum amylase concentration was normal. Chest radiography confirmed the presence of subcutaneous emphysema, and also showed gas in the mediastinum. Where had it come from? The radiograph did not show free gas under the diaphragm (figure). CT of the chest and abdomen showed gas in the mediastinum, with extensive tracking into soft tissues—but no evidence of oesophageal rupture or pneumothorax. CT also showed retroperitoneal and mesenteric gas. The patient was transferred to a surgical unit. An exploratory laparotomy showed extensive diverticular disease of the sigmoid colon, with a small perforation, and a walled-off abscess attached to the lateral pelvic wall. The surgeons did a Hartmann’s procedure, removing the sigmoid colon and fashioning a stoma. The patient’s recovery was uneventful. When last seen, in May, 2008, she was well. Supraclavicular emphysema is typically associated with a perforated gastric or duodenal ulcer. Subcutaneous emphysema of the neck is usually a consequence of rupture of a thoracic organ. Causes include pneumothorax, oesophageal perforation, tracheobronchial injury, surgery, and, more rarely, injury to the head and neck, or infection with gas-producing organisms, such as clostridium. Colonic disease can cause cervical subcutaneous emphysema1–3—but, perhaps unsurprisingly, this is rare. Subcutaneous emphysema caused by colonic perforation is usually in the perineum or anterior abdominal wall. So how did our patient end up with crepitus in the neck? Meyers characterised the retroperitoneal pelvic space as comprising three compartments: the anterior pararenal space, containing parts of the duodenum, pancreas, and ascending and descending colon; the posterior pararenal space, containing blood vessels and lymphatic vessels; and the perirenal compartment, containing kidneys, ureters, and great vessels.4 Air from a perforated viscus could travel, via the adventitia of blood vessels, to the anterior pararenal and perirenal compartments, and thence through the diaphragmatic aortic hiatus and caval foramen to the thorax.3 Contributors SKC and IA wrote the report. IA contributed to assessment and treatment.
Figure: An unusual sore throat (A) Chest radiograph, showing air in the mediastinum (arrow) and above the shoulder (arrowhead)—but not below the diaphragm. (B) CT at the level of the lower part of the liver, showing free air in the abdomen (arrows).
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References 1 Oetting HK, Kramer NE, Branch WE. Subcutaneous emphysema of gastrointestinal origin. Am J Med 1955; 19: 872–86. 2 Hur T, Chen Y, Shu GH, Chang JM, Cheng KC. Spontaneous cervical subcutaneous and mediastinal emphysema secondary to occult sigmoid diverticulitis. Eur Respir J 1995; 8: 2188–90. 3 Schmidt GB, Bronkhorst MW, Hartgrink HH, Bouwman LH. Subcutaneous cervical emphysema and pneumomediastinum due to a lower gastrointestinal tract perforation. World J Gastroenterol 2008; 14: 3922–23. 4 Meyers M. Radiological features of the spread and localization of extraperitoneal gas and their relationship to its source. Radiology 1974: 111: 17–26.
www.thelancet.com Vol 373 February 21, 2009
Where is the leak? Suresh Kumar Chhetri, Imran Aziz Lancet 2009; 373: 692 Department of Respiratory Medicine, Royal Albert Edward Infirmary, Wigan, UK (S K Chhetri MRCP, I Aziz FRCP) Correspondence to: Dr Imran Aziz, Department of Respiratory Medicine, Royal Albert Edward Infirmary, Wigan Lane, Wigan, Lancashire WN1 2NN, UK [email protected]
In March, 2007, an 84-year-old woman came to our emergency department. She had been unwell for 3 days— with a sore throat, a sense of fullness under her chin, and exertional shortness of breath. She had hypertension, osteoarthritis, and vertigo; she had had a cholecystectomy in the 1950s, and a laparotomy, for peritonitis of unrecorded cause, in her mid-teens. We found mild fever (temperature 38°C), but standard examination of the cardiovascular and respiratory systems, and the abdomen, revealed no abnormality. However, we found palpable crepitations over the neck, and in the supraclavicular fossae. Blood tests showed a high white-cell count (24∙7×10⁹ cells per L; neutrophil count 20∙4×10⁹ cells per L), ESR (67 mm/h), and concentration of C-reactive protein (254 mg/L). Tests of kidney and liver function showed no abnormality of note; A
B
the serum amylase concentration was normal. Chest radiography confirmed the presence of subcutaneous emphysema, and also showed gas in the mediastinum. Where had it come from? The radiograph did not show free gas under the diaphragm (figure). CT of the chest and abdomen showed gas in the mediastinum, with extensive tracking into soft tissues—but no evidence of oesophageal rupture or pneumothorax. CT also showed retroperitoneal and mesenteric gas. The patient was transferred to a surgical unit. An exploratory laparotomy showed extensive diverticular disease of the sigmoid colon, with a small perforation, and a walled-off abscess attached to the lateral pelvic wall. The surgeons did a Hartmann’s procedure, removing the sigmoid colon and fashioning a stoma. The patient’s recovery was uneventful. When last seen, in May, 2008, she was well. Supraclavicular emphysema is typically associated with a perforated gastric or duodenal ulcer. Subcutaneous emphysema of the neck is usually a consequence of rupture of a thoracic organ. Causes include pneumothorax, oesophageal perforation, tracheobronchial injury, surgery, and, more rarely, injury to the head and neck, or infection with gas-producing organisms, such as clostridium. Colonic disease can cause cervical subcutaneous emphysema1–3—but, perhaps unsurprisingly, this is rare. Subcutaneous emphysema caused by colonic perforation is usually in the perineum or anterior abdominal wall. So how did our patient end up with crepitus in the neck? Meyers characterised the retroperitoneal pelvic space as comprising three compartments: the anterior pararenal space, containing parts of the duodenum, pancreas, and ascending and descending colon; the posterior pararenal space, containing blood vessels and lymphatic vessels; and the perirenal compartment, containing kidneys, ureters, and great vessels.4 Air from a perforated viscus could travel, via the adventitia of blood vessels, to the anterior pararenal and perirenal compartments, and thence through the diaphragmatic aortic hiatus and caval foramen to the thorax.3 Contributors SKC and IA wrote the report. IA contributed to assessment and treatment.
Figure: An unusual sore throat (A) Chest radiograph, showing air in the mediastinum (arrow) and above the shoulder (arrowhead)—but not below the diaphragm. (B) CT at the level of the lower part of the liver, showing free air in the abdomen (arrows).
692
References 1 Oetting HK, Kramer NE, Branch WE. Subcutaneous emphysema of gastrointestinal origin. Am J Med 1955; 19: 872–86. 2 Hur T, Chen Y, Shu GH, Chang JM, Cheng KC. Spontaneous cervical subcutaneous and mediastinal emphysema secondary to occult sigmoid diverticulitis. Eur Respir J 1995; 8: 2188–90. 3 Schmidt GB, Bronkhorst MW, Hartgrink HH, Bouwman LH. Subcutaneous cervical emphysema and pneumomediastinum due to a lower gastrointestinal tract perforation. World J Gastroenterol 2008; 14: 3922–23. 4 Meyers M. Radiological features of the spread and localization of extraperitoneal gas and their relationship to its source. Radiology 1974: 111: 17–26.
www.thelancet.com Vol 373 February 21, 2009