J. Coloproctol. (Rio J.) vol.37 número1

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jcoloproctol(rioj).2017;37(1):47–49

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Case

Report

Colorectal

injury

by

compressed

air:

the

rule

of

conservative

therapy

Labib

Al-Ozaibi

∗

_,

_Zhwar

_Al-Jarrah

DubaiHealthAuthority,RashidHospital,GeneralSurgeryDepartment,Dubai,UnitedArabEmirates

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Articlehistory:

Received7February2015 Accepted20July2016

Availableonline5September2016

Keywords:

Compressedaircoloninjury Colonbarotrauma

Pneumaticbowelinjury

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Wearereportingacaseofcolorectalinjurycausedbyajetofcompressedairdirectedfroma distancetowardstheanus.Thepatientmentionedthatithappenedaccidentallywhilehis colleaguewascleaninghisclothesusingcompressedair.Thepatientpresentedwithacute abdominalpainanddistension.AcontrastCTstudydidnotshowanyfreeairorleakage.The patientwastreatedconservatively,progressedwellandwasdischargedfromthehospital onthefourthday.

licenses/by-nc-nd/4.0/).

Lesão

colorretal

por

ar

comprimido:

a

regra

da

terapia

conservadora

Palavras-chave:

Lesãodecolonporarcomprimido Barotraumadecolon

Lesãointestinalpneumática

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e

s

u

m

o

Descrevemosumcasodelesãocolorretalcausadaporumjatodearcomprimidodirecionado paraoânus,acertadistância.Opacientemencionouqueoocorridofoiacidental,enquanto umcolegaestavalimpandosuasroupascomarcomprimido.Opacienteseapresentoucom doresabdominaisagudasedistensão.UmestudodeTCcontrastadonãodemonstrouarlivre, nemvazamento.Opacientefoitratadoconservadoramente,teveboaevoluc¸ãoerecebeualta hospitalarnoquartodia.

licenses/by-nc-nd/4.0/).

Introduction

Colorectalinjuriesduetocompressedairareveryrareand,of thefewcasesmentionedintheliterature,nearlyallofthem

∗ _{Corresponding}_author_.

E-mail:lsalozaibi@gmail.com(L.Al-Ozaibi).

underwentsurgery.1,2_Most_of_the_reported_cases_were_due_to

thedeliberateinsertionofanairhoseintotherectum. How-ever,inthisparticularscenario,theactionwasaccidentaland directedfromadistance,withthecompressedairbeingused

http://dx.doi.org/10.1016/j.jcol.2016.07.001

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48

jcoloproctol(rioj).2 0 1 7;37(1):47–49

tocleandustofftheclothes.Duetotherarityofthemethod ofinjuryandthelackofliteratureonthecase,conservative treatmentcanbechallenging.

Case

presentation

A27-year-oldmanpresentedtotheEmergency Department complainingofabdominalpainanddistension.Heworkedin atyreshopandhadaskedacolleaguetocleantheclothesthat hewaswearingbyusingajetofcompressedair.Whiledoing so,thecolleaguepointedthehosetowardstheanalregion, and,althoughthehoseitselfwasnotplacedintotheanus,a jetofairblewthroughhisclothesandintotheanalopeningfor aroundonesecondduration.Immediately,thepatient experi-encedabdominaldistension,generalisedabdominalpainand shortnessofbreath.Hevisitedthebathroom,wherehepassed stoolmixedwithafewdropsoffreshblood,andvomitedtwice. Onehouraftertheincident,hearrivedintheEmergency Departmentandexperiencedafurtherepisodeofvomiting inthe triagearea.Hewasconsciousandvitallystable,and painontheVisualAnalogueScale(VAS)was8/10.On exami-nation,theabdomenwasdistendedandhyper-tympanicon percussion, andthere was tendernessand guarding inthe lowerabdomen.Localexaminationshowedanabrasionatthe analvergeatthe5o’clockposition.Rectalexaminationelicited tenderness,butnobleeding,andaproctoscopydidnotshow anyabnormalitiesapartfromthepresenceofloosestool.

Thepatientwasgivenmorphineandmetoclopramideand hadaurinarycatheterinserted.AbdominalX-rays(erectand supine)showed gasesandbowel distension,butnosign of freeair.ThelaboratorytestsgaveaC-reactiveprotein(CRP) of 59mg/dL (normal<10mg/dL), a white blood cell (WBC) countof19.7×109L(normal4.0–11.0×109L)andneutrophilia

(84.3%).Otherlaboratoryinvestigationswereunremarkable.A computedtomography(CT)scanoftheabdomen(withrectal contrast)showedthickening intherectalandsigmoidwall, withairinthewallandstrandingofthesurrounding mesen-tery.Therewasalsosubcutaneousemphysemaintheperianal region,aswellasatrootofthescrotum.Thescanshowed min-imalfreefluidcollectioninthesub-hepaticandrightparacolic regions,withnopneumoperitoniumandnocontrastleakage

(Figs.1and2).

Uponre-assessmentanhourlater,thepatient’spainhad decreasedandhisabdomenwasnowsoft,withmild tender-nessstillpresentintheleftiliacfossa.Adiagnosisofsealed perforationwasacceptedandthedecisiontakenwastotreat himconservatively.Hewasadmittedtothehospital,keptnil peroral(NPO)withintravenous(IV)fluidsandstartedonIV antibiotics(Tigecycline100mgstat dose,followed by50mg twicedaily).Hewasfollowedupbyserialphysical examina-tion.

Onthesecondday,theabdominalpainanddistensionhad furtherdecreasedandtheabdomenwassoftandnon-tender, andthepatientwasstartedonasoftdiet.Bythethirdday,the patienthadnoabdominalpain,waspassingnormalstoolsand wastoleratingafulldiet.Hisvitalsignswerenormalandhis abdomenwassoftandlax.Hisrepeatlaboratorytestsshowed thatCRPhaddecreasedfromtheinitial59mg/dLtoanewlevel of40mg/dL,andtheWBCcounthadnormalisedto9.1×109L.

Fig.1–Thicknessandairintherectalwallwith surroundingtissuehaziness,distendedboweland subcutaneousemphysema.

Ondayfour,hewasdoingwellandsowasdischargedfromthe hospitalwithoralantibiotics(Cefuroxime500mgtwicedaily forfivedays).Athisfollow-upappointmentintheclinicone weeklater,thepatienthadnocomplaints,hadnormalbowel motionsandhisabdomenwassoft.

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jcoloproctol(rioj).2 0 1 7;37(1):47–49

49 Discussion

Themajorityofcasesofcolorectalinjurybycompressedair areduetotheinsertionoftheairhosedirectlyintothe rec-tum,andthefirstsuchcasewasreportedbyStonein1904.3

However,thereareveryfewcasesreportedintheliterature wherebytheinjuriesoccurredwhiletheairhosewasheld out-sideofthepatient’sclothing,atadistancefromtheanus.4_In

suchacase,thewornclothingandtheanalsphinctersmight becomeweakenedduetothepressureandvolumeofthejet ofair,andthiscanalsocauseperforationorgangreneofthe bowelwithinashortperiodoftime.Thegangreneoccursdue tooverdistensionofthebowel,whichcompromisestheblood supply,orembolisationoftheinferiormesentericartery.5

Thevast majority ofreportedinjuries are inthe region of the antimesentric border of rectosigmoid. The patho-logiclesionsfollowingpneumaticinsufflationdependonthe resultantintraluminalpressure.Itcan includeserosal hae-morrhage,lacerationsoftheserosaandmuscularcoatwith bulgingof the mucous membrane, or complete rupture of the bowel through the serosa, muscular coat and mucous membrane.6_In_the_majority_of_cases,_the_injuries_were_only

seromuscularlacerations.Mehmet7_reported_a_case_in_which

there were multiple serosainjuries in all segments ofthe colon,especiallythesigmoidcolonandthecaecum,although therewasnoperforation.

Externalpneumaticinsufflationinjuryofthecolonthrough theanusdependsontheamountofairpressure,theairflow velocity,theanalrestingpressureandthedistancebetween thesourceandanus.Thejetofaircanpassthroughtheclothes andenterthebowelevenwhenitisnotaccuratelydirectedat theanus.Ithasbeensuggestedthatthethighs,buttocksand perineumformafunnelthathelpdeliverthestreamofairinto theanus.

Conservativemanagementistheruleforsuchinjuries.If noperforationisidentifiedradiologically,andthepatienthas nosignsofperitonitis,theinjurymightbejustseromuscular innatureandthepatientcanbemanagedconservatively. Sim-ilartoourcase,quiteafewotherpreviouscasesthatinvolved pneumaticbowel injurywithoutperforationwere managed non-operativelywithfullrecovery.8_If_perforation_has_occurred

andisevidentradiologically,butsignsofgeneralperitonism areabsentandthepatient’sconditionisgood,theperforation mighthavebeensealed.Insuchacase,expectant manage-mentshouldbeadopted.9,10

Conclusion

Colorectalinjuryshouldbesuspectedincompressedairinjury. Themajorityofcasesneedsurgicalintervention.Thedecision togoforconservativemanagementshouldbetakencautiously andguidedbytheclinicalsituationofthepatient.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.A copyofthewrittenconsentisavailable.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.SuhHH,KimYJ,KimSK.Colorectalinjurybycompressed

air-areportof2cases.JKoreanMedSci.1996;11:179–82.

2.RainaS,MachiedoGW.Multipleperforationsofcolonafter

compressedairinjury.ArchSurg.1980;115:660–1.

3.StoneGW.Acaseofruptureofthebowelcausedby

compressedair.Lancet.1904;164:216–7.

4.ZunzuneguiRG,WernerAM,GamblinTC,StephensJL,Ashley

DW.Colorectalblowoutfromcompressedair:casereport.J

Trauma.2002;52:793–5.

5.FarbinS,DavidsonP,ShockleyL.Perforationofthesigmoid

colonbyhydrostaticpressureofapublicwaterfountain.J

EmergMed.1996;14:703–6.

6.SyED,ChiuYI,ShanYS,OngRL.Pneumaticcoloninjury

followinghighpressureblowgundustcleanerspraytothe

perineum.IntJSurgCaseRep.2015;6C:218–21.

7.ErginM,OzerMR,KocakS,KarakusN,BabagilB,CanderB.A

rarecaseofcolorectalinjurywithcompressedair.JMed

Cases.2013;4:159–60.

8.BrownRK,DwinelleJH.Ruptureofthecolonbycompressed

air:reportofthreecases.AnnSurg.1942;115:13–20.

9.AdairHM,HishonS.Themanagementofcolonoscopicand

sigmoidoscopicperforationofthelargebowel.BJS.

1981;68:415–6.

10.GurayaSY.Thenonsurgicalmanagementofcolonoscopic

perforations:worthwhiletotakerisk.JTUMedSc.