P-136 Case of Diffuse Air Leak Associated with Colonoscopy in a Patient with Perianal Crohnʼs Disease

Abstract

BACKGROUND: Complications associated with colonoscopy are uncommon, particularly pneumothorax and pneumoperitoneum without bowel perforation. However, patients with perianal Crohn's disease may have fistulas penetrating multiple tissue planes, predisposing them for air dissection associated with insufflation. We present a case of a patient with perianal Crohn's disease with diffuse air leak during colonoscopy. METHOD(S): A 56 year old Caucasian female with Crohn's disease, complicated by perianal fistulas and small bowel obstruction requiring resection and diverting ileostomy, was referred to assess disease activity and feasibility for ileostomy take-down and surgical re-anastamosis with endoscopy. Ileoscopy showed normal mucosa and random biopsies were performed. Colonoscopy per rectum was then performed. Within several minutes of colonoscopy with air insufflation, the patient developed dyspnea, hypoxia and was noted to have crepitus along the anterior chest wall, neck, and face. The procedure was terminated and the patient was transferred to the emergency room. On assessment in the emergency room, she was afebrile with normal heart rate, respiratory rate, and oxygen saturation of 100% on 2 liters of oxygen. Her respiratory exam revealed decreased breath sounds and hyperresonance on the left side. Her abdomen remained soft without rebound, guarding or rigidity. Chest x-ray revealed a large left-sided tension pneumothorax with midline shift. A chest tube was placed in the left pleural space. A computed tomography (CT) scan of her chest, abdomen and pelvis demonstrated an interval right-sided pneumothorax, pneumomediastinum, pneumopericardium, subcutaneous air dissecting along the soft tissues of the chest wall and neck, extensive intra- and retroperitoneal air, and air dissecting into the subcutaneous tissues of the buttocks. A chest tube was subsequently placed in her right pleural space. Throughout her hospitalization, she denied abdominal pain and remained hemodynamically stable. She was managed conservatively with bilateral chest tubes, empiric broad spectrum antibiotics, and NPO status. On day 2, her diet was advanced and well tolerated. Her white blood cell count remained normal and her hemoglobin remained at baseline throughout her hospitalization. Bilateral chest tubes were removed on day 4. Repeat CT of her chest, abdomen and pelvis on day 5 showed significantly decreased free air in abdomen, pleural and pericardial spaces. RESULT(S): (Case report). CONCLUSION(S): We describe an unusual case of diffuse air leak with pneumothorax, pneumoperitoneum, pneumomediastinum and crepitus during colonoscopy in a patient with perianal Crohn's disease. We hypothesize the air leak developed through perianal fistulas, although the patient declined further evaluation of her perianal disease. The lack of peritonitis and her rapid recovery with conservative management argues against bowel perforation causing the air leak. Crepitus should be recognized during endoscopy as a sign of potential diffuse air leak. This case demonstrates that diffuse air leak without peritonitis after colonoscopy in a patient with Crohn's disease may be managed conservatively.