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hest Pain After Gastrointestinal Endoscopic ExaminationANS P. GROECHENIG,* WERNER VOGETSEDER,‡ and HERBERT TILG‡

Department of Internal Medicine, Academic Teaching Hospital Barmherzige Brüder, St Veit/Glan; and ‡Department of Internal Medicine, Academic Teaching

ospital, Hall, Austria

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36-year old man was referred to our hospital with intermit-tent abdominal pain and bloating. Routine gastroduodenos-

opy and ileocolonoscopy were performed without any visibleigns of pathologic gastric, duodenal, ileal, or colonic mucosa.outine biopsies were taken from gastric antrum and corpus,roximal duodenum, distal ileum, and from 4 different stages ofhe colon (ascending, transverse, descending, and sigmoid colon).ll biopsies were from macroscopic intact mucosa without anyleeding evidence or visible signs for acute perforation.

After an inconspicuous 2-hour observation period the patientas sent home. On the following day the patient returned to ourospital complaining about intense left-sided chest pain withadiation into his left arm. The patient reported that slight chestain started about 8 hours after demission and worsened overight. On clinical examination, both lung sides were clear onuscultation without signs for pneumothorax, no subcutaneoushoracic emphysema was noted, heart sounds were normal, andhe stomach was tender on palpation without any signs of peri-onitis. An electrocardiogram, cardiac enzymes, and D dimer wereithin normal limits.Because of free mediastinal, pericardial, and retroperitoneal air,

iagnosis of pneumomediastinum (white arrows, Figure A), pneu-opericardium (black arrow, Figure A), and retropneumoperito-

eum (white arrow, Figures B and C) was made. The patient wasdmitted for clinical observation and was designated as nothinger oral for 48 hours. Prophylactic antibiotic therapy (piperacil-

ine/tazobactam) and pain therapy were started. Computed to-ography of the chest and abdomen showed no signs for abscess

ormation. Follow-up x-rays showed gradual reabsorption of freeetroperitonal, mediastinal, and pericardial air. Histologic biopsyxaminations were normal. After a hospital stay of 4 days, the

atient was discharged symptom-free.

Retroperitoneal perforation is a rare complication after colonos-opy and gastroduodenoscopy, ranging between 0.1%–1%.

hereas several case reports were found in literature concerningetroperitoneal perforation after endoscopic gastrointestinal exam-nation associated with polypectomy, mucosectomy, or in patientsith active inflammatory bowel diseases or colonic cancer, thereere only few reports about perforations during routine endo-

copic examination and biopsy taking.1 Possible places for perfo-ation in our case could have been the biopsy sites in the duode-um, ileum, ascending or descending colon. All these parts haveotal (duodenum) or partial (ileum, ascending/descending colon)etroperitoneal position.

In contrast to intraperitoneal perforation with acute peritonitisymptoms and easy recognition on x-ray, retroperitoneal perfora-ion shows initially fewer symptoms and can be easily overlookedn x-ray.2 Most cases can be managed conservatively; a surgical

ntervention in patients without signs of peritonitis is seldomecessary.3

References. Girardi A, Piazza I, Giunta G, et al. Retroperitoneal, mediastinal

and subcutaneous emphysema as a complication of routine uppergastrointestinal endoscopy. Endoscopy 1990;22:83–84.

. Bejvan SM, Godwin JD. Pneumomediastinum: old signs and newsigns. AJR Am J Roentgenol 1996;166:1041–1048.

. Igbal CW, Chun YS, Farley DR. Colonoscopic perforations: a retro-spective review. J Gastrointest Surg 2005;9:1229–1235.

© 2008 by the AGA Institute1542-3565/08/$34.00

doi:10.1016/j.cgh.2008.02.039

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:xxxii