Indian Journal of Medical Case Reports ISSN: 2319–3832(Online) An Open Access, Online International Journal Available at http://www.cibtech.org/jcr.htm 2017 Vol.6 (2) April-June, pp. 18-20/Talluri et al. Case Report Centre for Info Bio Technology (CIBTech) 18 COLONOSCOPY AND BIOPSY ASSOCIATED BILATERAL PNEUMOTHORACES, PNEUMOMEDIASTINUM, PNEUMOPERITONEUM, PNEUMORETROPERITONEUM, AND SUBCUTAENOUS EMPHYSEMA Sriharsha Talluri 1 , Jayaram Thimmapuram 2 , Rajesh Panchwagh 3 and John Manze lla 4 1 Geisinger Commonwealth School of Medicine, Pennsylvania 2 Department of Internal Medicine, York Hospital, Pennsylvania 3 Department of Gastroenterology, York Hospital, Pennsylvania 4 Department of Infectious Diseases, York Hospital, Pennsylvania *Author for Correspondence ABSTRACT Endoscopic perforation is a serious complication of colonoscopy. However, bilateral pneumothoraces following colonoscopy has rarely been reported. We report a case of bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema following colonoscopy in a patient with no radiological evidence of colonic perforation. Our case emphasizes the need for clinicians to be cognizant of the supra-diaphragmatic complications of colonoscopy that may occur and that nonoperative management may be appropriate even in a patient with profound radiological signs. Keywords: Colonoscopy, Pneumothorax, Pneumomediastinum, Pneumoperitoneum, Subcutaneous Emphysema INTRODUCTION Endoscopic perforation of the colon is one of the most serious complications of colonoscopy. It may result in collection of air in the peritoneal cavity. However, bilateral pneumothoraces following colonoscopy rarely has been reported. We report a case of bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema following colonoscopy in a patient with no radiological evidence of colonic perforation. CASES A 49- year-old female with a history of ulcerative colitis (UC) underwent a colonoscopy. Her past medical history also included hypertension, depression, and endometriosis. Her medications included triamterene/hydrochlorothiazide, mesalazine and bupropion. She had been on prednisone 60 mg per day by mouth for a week due to flare up of her UC symptoms. Colonoscopy revealed severe ulcerative proctocolitis extending from rectum to approximately 30 cm in the sigmoid colon indicating an active flare of ulcerative colitis; however, the colonoscope was introduced to only mid-transverse colon because of poor colonic prep and the degree of inflammation in the left colon. Multiple biopsies were obtained from the inflamed part and the transverse colon, sigmoid flexure, proximal and mid-sigmoid colon. Approximately, 10 minutes after the procedure, the patient had a coughing episode, was unable to complete sentences without coughing and within 20 minutes she developed swelling and crepitus around the neck. Her vital signs showed a temperature of 98.1 F, pulse rate of 102 per min, respiratory rate of 20 per minute, blood pressure of 182/116 mm Hg. Oxygen saturations were 100% on 6 litres/min of nasal cannula. An urgent CT scan of neck, thorax, abdomen and pelvis revealed extensive air in the region of peritoneal and retroperitoneal space. Dilatation of colon with air fluid levels was noted. There was significant emphysematous change involving the face, neck and mediastinum with associated bilateral pneumothoraces. Subcutaneous emphysema also extended into chest wall bilaterally.