Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 180 Emergency 2014; 2 (4): 180-182 CASE REPORT Pneumatic Rupture of Rectosigmoid; a Case Report Mohammad Montazeri1, Bahman Farhangi2, Mahmood Montazeri1* 1. Young Researchers Club, Islamic Azad University, Babol Branch, Babol, Iran 2. Department of General Surgery, Shahid Beheshti Hospital, Mazandaran University of Medical Sciences, Babol, Iran Abstract Pneumatic rectosigmoid rapture is usually occurred following the inappropriate fun by direct entering a high vol- ume of the air through the pneumatic device to the anus. Such an event was reported for the first time in 1904 by Stone. Diagnosis and treatment of such injuries are often delayed because of some social limitations and preventing the patient form explaining the event. Colon sigmoid rupture and pneumoperitoneum is one of the most dangerous and life treating complications of entering a high volume of the air to the rectum in a short time. There are only a few reports regarding the similar cases. Here, a case of pneumatic rectosigmoid rapture was reported in a 53 year- old male following an inappropriate fun. Key words: Pneumoperitoneum, artificial; rupture; abdomen, acute Cite this article as: Montazeri M, Farhangi B, Montazeri M. Pneumatic rupture of rectosigmoid; a case report. Emergency. 2014;2 (4):180-2. Introduction:1 neumatic rectosigmoid rupture is usually oc- curred following the inappropriate fun by direct entering a high volume of the air through the pneumatic device to the anus (1). There are only a few reports regarding the similar cases. Such an event was reported for the first time in 1904 by Stone (2). Then Andrews in 1911 declared a patient with sigmoid rap- ture who was treated by resection of torn region (3). Diagnosis and treatment of such injuries are often de- layed because of some social limitations and preventing the patient form explaining the event. Colon sigmoid rupture and pneumoperitoneum is one of the most dangerous and life treating complications of entering a high volume of the air to the rectum in a short time (4). Here, a case of pneumatic rectosigmoid rapture was reported in a 53 year-old male following an inappropri- ate fun. Case presentation: A 53 year-old patient with complaining of faint and ab- dominal pain referred to the emergency department. His problem was suddenly initiated with rectoragy and low- er abdominal pain in the admission morning. At first he referred to the outpatient clinic, underwent supportive treatment, and then discharged without a clear diagnosis. After a short time, he experienced non-bloody vomiting of eaten stomach content as well as rectoragy, again. Also the abdominal pain exacerbated and expanded to across the abdomen. Shortness of breathing was gradually add- *Corresponding Author: Mahmood Montazeri; Young Researchers Club, Islam- ic Azad University, Babol Branch, Babol City, Mazandaran Province, Iran. Tel: +98 111 2415102; Email: mm.montazeri@gmail.com; Received: August 2014; Accepted: August 2014 ed to other problems of the patient, too. By increasing the patient’s symptoms, he was referred to the emergen- cy department by his colleagues. The patient did not ex- plain anything regarding his trauma event and stated that he had has these symptoms since the morning. In the arrival time the patient was alert but complained from severe abdominal pain and rectoragy. During visiting the abdomen was distant with general guarding and tender- ness. The abdomen was tympan in palpitation and dull- ness of the liver wiped out. Visiting of the rectum showed no signs of trauma or injury. After comprehensive histo- ry taking and physical examination, laboratory tests as well as a simple standing chest radiography was re- quested. The patient’s vital signs at the time of admission were as follow: Blood pressure= 120/80 mmHg, pulse rate= 100/minutes, respiratory rate= 20/minutes, tem- perature= 37.5 °C oral, and saturation oxygen= 91% on room air. Plain chest radiograph revealed a high volume of free air under the both sides of diaphragm (Figure 1). Then, the patient experienced fever during hospitaliza- tion (39 °C oral). Considering to the signs, the subject underwent laparotomy after the initial resuscitation. Immediately after opening the peritoneum, the air quick- ly exited and abdominal distension relieved rapidly. The exploration showed a gangrene and about six centime- ters perforation at anti-mesenteric border of the rec- tosigmoid. In careful observation of the peritoneal space no other injuries were found. After clearing the peritone- al cavity, the patient underwent Hartmann’s colostomy and also Hemovac drain was placed. After full conscious- ness of the patient and his informing from the occurred event, he stated that in the refer morning before begin- ning of the symptoms, his colleagues for the fun entered P mailto:mm.montazeri@gmail.com This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 181 Montazeri et al the compressed air through the tube air compressor (with pressure lbs 50) into his anal. Two weeks after surgery, the patient was discharged in a good condition. Discussion: Pneumatic rectosigmoid rupture usually happen follow- ing the joke and in work places using compressed air. Among pneumatic traumas, colon injury is very serious due to entering a high volume of the air to the rectum in a short time. The symptoms are different depend on the intraluminal pressure and level of colon injury. Colon rapture can be occurred in one or more sites but as shown in the subject of the present study, the most cur- rent region of the rapture is the rectosigmoid location especially in the recto-sigmoid Junction (5). The high pressure air which is entered to the rectum exercises a large force to the rectosigmoid Junction which leads to rapturing the anti-mesenteric wall of the rectosigmoid (3). The abdominal distension and pain are suddenly initiated and peritoneal symptoms like abdominal rigid- ity and tenderness presented as the subject of our study. Due to hampering the movement of diaphragm by pneumoperitoneum, in most of times respiratory distress occurs, too (4). Zechel divided the shock of pneumatic injuries in to two groups (6). The initial shock is because of entering the compressed air and colon rapture while the second shock arises from the pressure pneumoperitoneum. In the pressure pneu- moperitoneum too much pressure in the peritoneum forces to the cardiovascular and respiratory system and leads to hypotension and respiratory distress. After resuscitation of the initial shock, peritonitis due to fecal contamination should be evaluated and quickly treated (1). The inflamed colon filled with air or large amount of free air in peritoneal space was seen in radiography. When the respiratory distress associates with such ra- diological presentation, arterial blood gas (ABG) shows hypoxia and respiratory alkalosis. Increasing the air pressure inside of the peritoneal space can affect supe- rior vena cava (SVC) and collapse the blood flow, severe impairment of blood flow leads to rhabdomyolysis (7). Although patients with pneumatic rapture of colon were diagnosed in the initial visit, some cases with de- layed diagnosis were also reported (8-10). Such pa- tients firstly did not show any peritoneal symptoms or air trapped in the peritoneal cavity in the simple chest radiography, but after three to five days the peritoneal symptoms would gradually appear. Shiels and col- leagues showed that a pressure of 120 mmHg is re- quired to colon perforation by hydrostatic enema (11); also in the present subject such a pressure was oc- curred by injecting the air to the anus. Of course deter mining the reason of perforation, arisen from the direct trauma or hydrostatic pressure, is difficult. Treatment of pneumatic injury has two aspects: Pressure pneu- moperitoneum and colon injury. Pressure pneumoperi- toneum mostly causes to acute respiratory distress with or without cardiovascular collapse and in the absence of emergency peritoneal paracentesis it will lead to death. Colon perforation should be separately treated. For the perforated colonic ulcer, the primary repair or segmen- tal resection with or without colostomy would be per- formed, too (4). It could be concluded that despite un- commonness of pneumatic rectosigmoid rupture, it should be considered as one of the differential diagnosis in the presence of free air in abdominal cavity and sign of peritoneum. Acknowledgments: None Conflict of interest: Authors declared no conflict of interest. Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu- tion based on recommendations of the International Committee of Medical Journal Editors. References: 1. Kumar R, Rowe T, Dave P. Pneumatic rupture of colon. Postgrad Med J. 1971;47(551):631-2. 2. Stone G. Rupture of bowel caused by compressed air. The Lancet. 1904;164(4221):216-7. 3. Andrews EW. Pneumatic rupture of the intestine, a new type of industrial accident. Surg Gynecol Obstet. 1911;12:63- 72. 4. Kim SJ, Ahn SI, Hong KC, Kim JS, Shin SH, Woo ZH. Pneumatic colonic rupture accompanied by tension pneumoperitoneum. Yonsei Med J. 2000;41(4):533-5. Figure 1: The upright posterior-anterior chest x ray of patients This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 182 Emergency 2014; 2 (4): 180-182 5. Brown RK, Dwinelle J. Rupture of the colon by compressed air: report of three cases. Ann Surg. 1942;115(1):13. 6. Zechel GL. Pneumatic rupture of the colon as an industrial injury. Ind Med Surg. 1967;36(10):663-7. 7. Kinjyo T, Ohno T, Tanaka K, Nishimura A, Taira A. Compressed air injury of the colon complicated by rhabdomyolysis: case report. J Trauma. 1994;36(4):592-3. 8. Raina S, Machiedo GW. Multiple perforations of colon after compressed air injury. Arch Surg. 1980;115(5):660-1. 9. Gemer M, Feuchtwanger MM. Pneumatic rupture of the colon: sequential appearance of symptoms. JAMA. 1975;233(4):355. 10. Comline J. Pneumatic rupture of the colon. Br Med J. 1952;1(4761):745. 11. Shiels 2nd W, Kirks D, Keller G, et al. John Caffey Award. Colonic perforation by air and liquid enemas: comparison study in young pigs. Am J Roentgenol. 1993;160(5):931-5.