Case report BMJ Case Rep: first published as 10.1136/bcr-2020-236369 on 3 November 2020. Downloaded from Subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum after upper gastrointestinal endoscopy Amr Elmoheen ,1,2 Mahmoud Haddad,1 Khalid Bashir,1,2 Waleed Awad Salem1,2 1Emergency Department, Hamad SUMMARY body in the throat, so he was scheduled for CT of Medical Corporation, Doha, Upper gastrointestinal (GI) endoscopies are performed the neck, which showed an air- fluid level at the mid Qatar oesophageal part likely due to gastro- oesophageal 2 for several reasons. The overuse of endoscopy has QU Health, College of negative effects on the quality of healthcare and junction abnormality (figure 1). He was assessed by Medicine, Qatar University, pressurises endoscopy services. It also results in the gastroenterologist in the emergency department Doha, Qatar the complications. These complications include and scheduled for upper GI endoscopy to rule out eosinophilic oesophagitis. The upper endoscopy Correspondence to pneumoperitoneum, pneumomediastinum and Dr Amr Elmoheen; subcutaneous pneumomediastinum. However, it showed a food bolus impacted at the distal end of Aelmoheen@ hamad. qa is worth noting that these complications rarely the oesophagus and pushed down in the stomach occur during endoscopy of the upper GI tract. These with slight trauma to the mucosa (figure 2). During Accepted 4 October 2020 complications, when they occur, indicate perforation the procedure, the gastroenterologist noticed that of the retroperitoneal space or peritoneal cavity. In that patient became tachycardic and developed this article, we discuss a case of pneumoperitoneum, surgical emphysema on the neck and cheek, so the pneumomediastinum and subcutaneous emphysema procedure aborted, and the patient shifted back to after upper GI endoscopy. the emergency department. On arrival, his vital signs were as follows: the temperature was 36.6°C, heart rate of 123 beats per minute, with a blood pressure of 123/64 mm Hg, BACKGROUND respiratory rate of 19 breath per minute and oxygen Excessive use of upper gastrointestinal (GI) endos- saturation 97% on room air. On physical examina- copy is increasingly becoming a global concern.1 tion, he was alert and oriented to time, place and According to estimates, about 56% of upper GI person with a Glasgow Coma Scale of 15. There procedures are conducted inappropriately.2 3 Inap- was an evident palpable surgical emphysema on the propriate use of upper GI endoscopy is accompa- right cheek (figure 3), anterior neck and the upper http://casereports.bmj.com/ nied by a risk of severe complications, high costs anterior chest. The trachea was centralised, and and low diagnostic yield.4 Dysphagia is difficulty chest auscultation revealed decreased air entry on swallowing, a common disorder, and an indication the right- side chest compared with the left side. The for several diagnostic procedures.5 6 Most cases of rest of the physical examination was unremarkable. dysphagia are associated with oesophageal causes, thus requiring oesophageal- gastro- duodenoscopy (examination of the upper GI tract) as the primary Investigations examination. It has been established that inap- The white cell count was elevated to 17.3 ×109/L propriate employment of upper GI endoscopy is of blood with neutrophilic predominance. Other associated with several risks and complications.6 blood investigations, including electrolytes, blood Pneumoperitoneum, pneumomediastinum and gas analysis, kidney functions and liver functions, on September 25, 2021 by guest. Protected copyright. subcutaneous emphysema are complications of were unremarkable. upper GI endoscopy, which, however, occur in rare 7 cases. This article presents a rare case of pneu- Differential diagnosis moperitoneum, pneumomediastinum and subcuta- Chest point- of- care ultrasound (POCUS) was neous emphysema after endoscopy of the GI tract. performed at the bedside and manifested the pres- ence of right- side lung point (video 1), absence of CASE PRESENTATION pleural sliding, and M- mode barcode sign on the © BMJ Publishing Group An 18- year-old male patient presented to the right side of the chest (figure 4). Chest radiography Limited 2020. Re- use emergency department with dysphagia. The early showed extensive subcutaneous emphysema, pneu- permitted under CC BY- NC. No morning before the presentation, he had eaten a momediastinum and small right- sided pneumo- commercial re- use. See rights and permissions. Published piece of meat, after which he started to feel that thorax (figure 5). All these manifestations raised by BMJ. something is stuck in his throat. He was extremely the concern for possible oesophageal perforation. uncomfortable, and after many attempts, he spat So, the patient started on broad-spectrum antibi- To cite: Elmoheen A, part of it out. Since then, he was unable to eat or otics and sent for urgent contrast CT of neck and Haddad M, Bashir K, et al. BMJ Case Rep drink due to difficulty and painful swallowing. In thorax with Omnipaque dye, which is water- soluble 2020;13:e236369. the emergency department, he was vitally stable, radiographic contrast. The CT revealed features doi:10.1136/bcr-2020- and his physical examination was unremarkable. suggestive of oesophageal perforation (interruption 236369 Fibre optic examination failed to detect any foreign of the lateral wall of the lower oesophagus and faint Elmoheen A, et al. BMJ Case Rep 2020;13:e236369. doi:10.1136/bcr-2020-236369 1 Case report BMJ Case Rep: first published as 10.1136/bcr-2020-236369 on 3 November 2020. Downloaded from Figure 1 CT of the neck, which showed an air- fluid level (red arrow) at the mid oesophageal part likely due to gastro- oesophageal junction abnormality. Figure 3 Palpable surgical subcutaneous emphysema reaches on the right cheek. contrast leak with the surrounding air at the site of the gastro- oesophageal junction). The CT also showed pneumomedias- Outcome and follow-up tinum, right pneumothorax, pneumoperitoneum in the upper After a few days, he stepped down to the surgical ward, and he abdominal slices and subcutaneous emphysema, which extended started to tolerate oral fluid intake, the pneumothorax resolved to the right cheek (figures 6 and 7). without intervention, and he was discharged from the hospital with a jejunostomy feeding tube in place. The final histology from endoscopic biopsies confirmed the diagnosis of eosino- Treatment philic oesophagitis. He was taken to the operation theatre by the GI surgeon for diagnostic laparoscopy, intraoperative upper GI endoscopy and DISCUSSION laparoscopic feeding jejunostomy. The intraoperative finding Dysphagia is a Greek terminology that refers to ‘disordered was negative for gastric or oesophageal perforation with a nega- eating’. Typically, the term dysphagia means difficulty in swal- tive bubbling test, but there was partial-thickness laceration at lowing. It is an important and very serious symptom and requires the distal oesophagus. a medical emergency when associated with chronic bleeding of After the procedure, the patient was admitted to the surgical the GI tract, dyspepsia, persistent vomiting, progressive unin- http://casereports.bmj.com/ intensive care unit, and the pneumothorax was treated conserva- tentional weight loss, epigastric mass, deficiency anaemia and tively. A swallow test with oral contrast showed the free passage other upper GI symptoms. Several conditions affecting the of contrast dawn to stomach without delay, contrast leak or upper GI may contribute to dysphagia. These conditions may be extravasation. malignant or benign. Among these include structural or neuro- muscular disorders that result in dysmotility of the oesophagus or oropharynx. Although the precise prevalence of dysphagia remains unknown, studies suggest that it may be within the range of 16%–22% after 50 years of age.7 8 The presentation of a pneumomediastinum is an indication that an air- retaining mediastinal structure has been breached. on September 25, 2021 by guest. Protected copyright. The air in the mediastinum tissues enters through the air passageway, for instance, after subjecting the pharynx to blunt Figure 2 Upper gastrointestinal endoscopy showed abnormal mucosa of the oesophagus with furrows and narrowing with food bolus impacted at the distal end. The food bolus was pushed down in the Video 1 M- mode of the point- of- care ultrasound on the right side of stomach with slight trauma to the mucosa. the chest showing lung point and barcode sign 2 Elmoheen A, et al. BMJ Case Rep 2020;13:e236369. doi:10.1136/bcr-2020-236369 Case report BMJ Case Rep: first published as 10.1136/bcr-2020-236369 on 3 November 2020. Downloaded from Figure 6 Contrast CT of neck and thorax showing pneumomediastinum (blue arrow), right pneumothorax (red arrow) with Figure 4 M- mode of the point- of- care ultrasound (POCUS) on the surgical emphysema in the neck (green arrow) and pneumoperitoneum right side of the chest showing barcode sign (red arrow). in upper abdominal slices (purple arrow). trauma, hypopharynx, facial bones, main stem bronchi and the trachea. Dental care techniques, Valsalva manoeuvre, GI perfo- II gastroenterostomy or mucosa of the gastric mucosa by the ration and severe straining may trigger the appearance of subcu- endoscopic tip. This would allow entry of insufflated air into taneous emphysema and pneumomediastinum.8 the wall. Pressurisation of the sensory segment of the Billroth In a freely perforated GI tract,