Tension Fecopneumothorax.

Fecopneumothorax causing tension (hemodynamic compromise) is an extremely rare situation, mostly as a result of blunt trauma. Here, we present an 86-year-old gentleman who presented with tension fecopneumothorax, with an interesting backstory as to the development of fecopneumothorax. Copyright:

INTRODUCTION

The presence of air and fecal matter in the pleural cavity is termed as fecopneumothorax. This is a very rare variant of hydropneumothorax, with only 18 cases reported so far, most of them following blunt trauma. Here, we present an 86-year-old gentleman who presented with breathing difficulty and hemodynamic compromise, ER workup leading to a diagnosis of tension hydropneumothorax which on chest tube insertion drained air and fecal matter. Careful history reviews lead to the discovery of an interesting backstory as to the development of this tension fecopneumothorax.

CASE REPORT

86-year-old gentleman with a background history of diabetes mellitus and coronary artery disease was referred to our center with complaints of breathing difficulty for 4 days and an episode of syncope at residence on the day before arrival to this center. On primary survey, the patient was found to be in respiratory distress and compensated circulatory shock. Air entry was absent in the left hemithorax. There was a sinus/fistulous tract of 2 cm diameter, covered by a colostomy bag in the left hypochondrium. The patient was started on oxygen therapy, intravenous fluid administration along bedside chest X-ray and point-of-care lung ultrasound examination. Left hydropneumothorax with the presence of straight-line demarcation with collapsed left lung was seen in chest X-ray [Figure 1]. Hydro point indicative of hydropneumothorax was seen in lung ultrasound. During evaluation, the patient developed ventricular tachycardia and was found to have acute anterior wall myocardial infarction in postcardioversion electrocardiogram. Emergency coronary angiogram showed ostial calcific left main coronary artery with triple vessel disease. Emergency primary percutaneous coronary intervention to the left anterior descending artery was done. The patient remained in respiratory distress and progressed to hypotensive shock requiring vasopressors. RUSH protocol ultrasound examination revealed features of obstructive shock which was corroborated by an elevated central venous pressure (13) and good left ventricular (LV) function postpercutaneous coronary intervention. Hence, a diagnosis of obstructive shock was made with left hydropneumothorax being the culprit cause. Left pleural space was decompressed with intercostal drainage tube, and 1 L of feculent liquid and air was drained [Figure 2a and b]. Hemodynamic status improved postdecompression and the patient was shifted for computed tomography (CT). CT showed herniation of large bowel loops into the left pleural space through a defect in the left diaphragm displacing the stomach and spleen medially [Figure 3]. Other CT findings were moderate left-sided hydropneumothorax with underlying collapse/consolidation and mild pericardial effusion.

Figure 1

Chest X-ray showing left hydropneumothorax (original picture)

Figure 2

(a) Intercostal Drainage (ICD) tube draining feculent liquid and air (original) (b) Post ICD insertion chest X-ray

Figure 3

Computed tomography thorax showing left diaphragmatic hernia

History analysis revealed that the patient was symptomatic with abdominal pain for 5 months before presentation. At the onset period of abdominal pain, the patient had been evaluated elsewhere and had been diagnosed with colonic diverticulosis and colonic polyps by colonoscopy assessment and colonic polypectomy was done. Histopathological examination was suggestive of tubulovillous adenoma. Postprocedure, the patient developed subdiaphragmatic abscess which was managed conservatively. At 2 weeks postprocedure, the patient developed constipation and decreased appetite. Ultrasound examination revealed 20cc residual collection with air pockets in subdiaphragmatic area in this patient. At 7 weeks postpolypectomy, the patient developed left hypochondrial pain and ultrasound revealed heterogeneous collection of 38.5 mL in perisplenic region. Hence, laparoscopic abscess drainage and drain placement were done under general anesthesia 7 weeks postpolypectomy. Postoperative summary described thick-walled left subdiaphragmatic abscess forming an inflammatory mass with the omentum, left lobe of the liver, greater curvature of the stomach, and splenic flexure of the colon containing 100 mL of thick pus. Pus culture revealed Escherichia coli. 10 days postlaparoscopy, review ultrasound revealed left subdiaphragmatic loculated collection of 15 mL along the superior aspect of the spleen with mild left pleural effusion. At 8 weeks postlaparoscopy, the patient developed acute onset breathing difficulty and one episode of syncope at residence which lead to the current presentation.

Hence, the tension fecopneumothorax was attributed to colonic diverticulosis – colonic polyps (tubulovillous adenoma) attempted biopsy of the same could have resulted in large bowel perforation which would have progressed to the subdiaphragmatic abscess. Postabscess drainage, an iatrogenic enterocutaneous fistula developed with enteropleural extension leading to left-sided diaphragmatic hernia of the large bowel. The scenario was complicated by acute coronary syndrome and uncontrolled diabetes.

The patient was admitted and surgical repair under high risk of major adverse cardiac events was offered. Surgery could not be carried out as the patient hemodynamics deteriorated with septic shock, and he finally succumbed to the illness.

DISCUSSION

The presence of fecal matter and air in the pleural cavity is called fecopneumothorax. This unusual event occurs when there is a diaphragmatic defect leading to herniation of the intra- abdominal contents into the pleural cavity and a tear/laceration in the colon leading to colopleural fistula. Most reported cases from worldwide suggest trauma to be the most common cause of which delayed presentation of blunt or penetrating trauma as reported by Beshay et al.,[1] Vermillion et al.,[2] and Green et al.[3] Other rarely reported causes include strangulated hernia loops, malignancy, Crohn's disease, and postesophagectomy.[4] Intrathoracic colon herniation and particularly, fecopneumothorax are very infrequent but life-threatening complications of esophagectomy.[5] To the best of our knowledge, this might be the first case possibly resulting from colonoscopic adenoma excision followed by laparoscopic abscess drainage.

The patients usually present with breathing difficulty (94.7%), cough (93%), fever (87.7%), chest pain (71.9%), weight loss (68.4.2%), loss of appetite (93.2%), tachypnea (68.4%), and tachycardia (49.1%).[6] In our case, the patient had recurrent abdominal pain and systemic complaints, which, if properly addressed in time would not have progressed to development of respiratory complications.

Pathologically, the left diaphragmatic dome is involved in 70%–90% of cases, given the protective role of the right liver. The hernial content is variable; the organs most frequently found in these hernias are in decreasing order of frequency: stomach (31.8%), colon (27.2%), omentum (15.9%), small intestine (13.6%), spleen (6.8%), and liver (4.5%). Pathophysiologically, tension fecopneumothorax is due to the perforation of the necrotic intestine in the hemithorax. This necrosis is secondary to ischemia of the intestinal segment volvulated or strangled at the diaphragmatic defect.[78]

Diagnosis of fecopneumothorax is based on meticulous clinical examination and additional diagnostic procedures. Examination findings are decreased breath sound over the affected hemithorax, straight-line dullness, shifting dullness, coin sign, and hippocratic succussion.[9] Hemodynamic instability with engorged neck veins and high intrathoracic pressure indicative of tension pneumo/hydropneumothorax. In this case, in addition to the above, an elevated central venous pressure with good LV function in the background of hypotensive shock led to the detection of obstructive shock due to tension fecopneumothorax.

Lung ultrasound plays a good role as bedside diagnostic tool. In addition to the presence of absent lung sliding anteriorly with bar code sign and lung point suggestive of air in pleural space, presence of “hydro-point,” i.e., point of air-fluid interspace seen in lung ultrasound is highly specific to the diagnosis of hydropneumothorax.

Chest X-rays demonstrate an elevated hemidiaphragm with bowel loop in the chest wherein our patient had an already perforated bowel in the left hemithorax depicting finding suggestive of hydropneumothorax. Barium studies depict the colopleural fistula with contrast leaking into the pleural cavity; however, this could not be done due to the hemodynamic instability of the patient. CT thorax and abdomen are more accurate as evidenced by this case. There is no role of conservative management and treatment is surgical.

CONCLUSION

Fecopneumothorax is a rare entity and can present as complication of intra-abdominal scopy procedures in addition to the reported cases of blunt trauma complications. Primary survey with stabilization of airway, breathing, and circulation are the utmost priority, followed by chest decompression and definitive surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal the patient identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (http:// www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.