Diffuse Emphysema Following a Double Contrast Enema

Abstract

The case to be reported presents the most unusual accident following an x-ray examination of the gastro-intestinal tract that has ever occurred in our experience. It is believed that the details may be of interest to radiologists. A. Z., a white male aged fifty-eight, was referred to the X-rav Department for an examination of the gastro-intestinal tract because of some vague digestive disturbances. The stomach showed a large deformity involving the lower half which was interpreted as due to a new growth. On the following day a barium enema revealed a poorly filled cecum. In order to determine the nature of the deformity more accurately, a contrast enema was given in the same manner as in many similar previous examinations. The air was injected by means of a Politzer bag with the patient lying on his abdomen. The nozzle was introduced by sight after bcing thoroughly lubncated, without undue pressure. When the injection of air was commenced a peculiar squeaking noise was heard and a great deal of resistance was experienced during the squeezing of the bulb. Since it was thought that the nozzle might be obstructed, it was withdrawn and examined for any possible obstruction of the lumen, but none was found. Neither was any blood noted upon the nozzle which might suggest traumatism to the rectal mucosa. The nozzle was carefully reintroduced with the same results as before. When the patient began to feel fullness of the abdomen a roentgenogram was made (Fig. 1). To our great surprise instead of finding air in the bowel it was seen in the retroperitoneal spaces, especially around the kidneys. The patient was then examined in the erect position to see if there was free air in the peritoneal cavity, but none was noted. Since the patient appeared to be none the worse for his experience he was allowed to go home and advised to stay in bed. Three hours later he returned because of difficulty in swallowing and more or less labored breathing. Examination revealed marked emphysema of the neck, and a roentgenogram showed air in the fascial planes of the neck and retropharyngeal region (Fig. 2). Air was also present in the anterior mediastinum and below the diaphragm (Fig. 3), apparently between the muscle and peritoneal membrane, since no free air was found in the peritoneal cavity. After a consultation with the surgeons it was decided to leave the patient alone and watch him for any possible untoward developments. Within several days the symptoms referable to the emphysema entirely disappeared and x-ray examination failed to demonstrate any free air in the tissues. A proctoscopic examination was made in order to confirm a suspected fistulous tract which was thought to be present, but neither palpation nor inspection revealed anything unusual with thc exception of internal hemorrhoids. Subsequently the patient was operated upon for the carcinoma of the stomach, which was found to be inoperable. He died a week later. No autopsy was obtained.