The rectosigmoid junction has limited mobility due to its bilateral fixation thus, compressed air insufflation with high velocity can cause rectosigmoid colonic barotrauma. The sudden high-velocity insufflation of air induces extreme shear force at the point of maximal fixation. The velocity of airflow is as significant as the actual intraluminal pressure in the occurrence of bowel injury. The order of resistant strength to intraluminal pressure was rectum, sigmoid colon, ileum, esophagus, jejunum, transverse colon, caecum, and stomach. Due to the ease of increase of the intramural pressures in the rectosigmoid junction in the colon, this area is considered the most vulnerable site for rupture in situations of noniatrogenic colorectal barotrauma. The difference between simple pneumoperitoneum and tension pneumoperitoneum is the presence of enormous tension in the peritoneal space, which can have fatal hemodynamic and respiratory consequences and the presence of such a condition carries high mortality unless an emergency intervention is done. Such colorectal injuries can either present with a tension pneumoperitoneum or can present without a tension pneumoperitoneum. Although there is an increased and widespread use of compressed air in modern life and there have reports of such noniatrogenic colorectal injuries from time to time, fortunately, colorectal injuries by compressed air are still not common. The first such case was reported by Stone in 1904. Noniatrogenic injuries are mostly due to misuse of compressed air which may be accidentally done or intentionally done as a part of a prank as seen in our patient. Woltjen reported four cecal perforations during 3000 colonoscopy procedures. A mild type of iatrogenic barotrauma to the colon can lead to “Cat scratch” colon, which was defined as bright erythematous linear marks resembling scratches, whereas severe iatrogenic barotrauma can even result in a bowel perforation. Most of these iatrogenic injuries are due to colonoscopic procedures. Colorectal barotrauma may be due to either iatrogenic or noniatrogenic causes. The postoperative period was uneventful and the patient was discharged with a functioning loop colostomy.īarotraumas in the gut are due to the pressure effect of either air or liquid which exceeds the caliber of the gut. Serosal tears in the colon were sutured with 3-0 Vicryl. A transverse loop colostomy was constructed and the rectal tears were sutured with 3-0 Vicryl by interrupted sutures. On opening the peritoneum, the following were found: (1) distension of large bowel and small bowel (2) long-segment serosal tear anteriorly along the upper rectum, sigmoid for a length of 20 cm (3) another segment of serosal tear along the anterior wall of transverse colon (4) long-segment serosal tears in the caecum, anteriorly and posteriorly for a length of 7 cm. We initially proceeded to construct a transverse loop colostomy for fecal diversion to facilitate healing of rectal wounds and to relieve the distension, but on encountering further injuries as mentioned below, we proceeded with an exploratory laparotomy to repair the other injuries. A long tear of about 8 cm posteriorly in the rectum at around 5 cm from the anal verge was identified. Ĭomputed tomography of the abdomen and pelvis revealing evidence of air pockets in the ischiorectal fossa and pelvisĪn extraperitoneal rectal injury was suspected from the above scenario and the patient was examined under general anaesthesia. Computed tomography scan of the abdomen revealed evidence of air pockets in both ischiorectal fossae and pelvis with subcutaneous emphysema tracking to intramuscular plane noted at the lower chest wall, the lower anterior abdominal wall around the perineal region, pelvic region, and scrotum with large bowel loops appearing grossly dilated. X-ray abdomen erect revealed dilated bowel loops. Digital rectal examination revealed a defect of 1–2 cm in the lower rectum at about 4–5 cm from the anal verge with no blood staining of gloved fingers with a normal sphincter tone. Abdomen examination showed mild abdomen distension with tenderness in the umbilical and hypogastric region, with subcutaneous emphysema in the abdomen wall extending up to the lower chest. The patient presented to us after nearly 1 day and a clinical examination revealed a pulse rate of 76/min, blood pressure of 110/72 mm of Hg, and respiratory rate of 20/min. Following this event, the patient immediately developed giddiness and breathlessness. After a detailed history, he revealed that as a prank played by his friends, there was the placement of a nozzle into his external anal orifice and release of highly compressed air through it, the previous day in his workshop. A 22-year-old male, who was a car mechanic by occupation, presented to us with complaints of abdomen discomfort for several hours.
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