Sigmoid perforation with retroperitoneal abscess and retroperitoneal air tracking into mediastinum

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What would be your next step in managing this patient?

What is the most likely source of mediastinal air? What is the diagnosis?

Pulmonary and Critical Care Pearls

Answers: Exploratory laparotomy; perforated viscus.

Diagnosis: Sigmoid perforation with retroperitoneal abscess and retroperitoneal air tracking into mediastinum.


Pneumomediastinum, or air in the mediastinum, was first described as a complication of trauma in 1819 by Laennec. Spontaneous pneumomediastinum as an entity was initially introduced into the medical literature in 1939 by Hamman, from which “Hamman sign” (air crepitus heard on auscultation with each heart beat) is derived. Pneumomediastinum is usually regarded as a benign, self-limited process that does not require medical intervention, although the etiology must be assessed to exclude rare life-threatening causes. Typical causes of pneumomediastinum are as follows:

1. Secondary to increased intrathoracic pressure, ie, Valsalva maneuver, strenuous exercise, weight lifting, vaginal delivery, and vomiting.
2. Sniffing cocaine or other Viagra pills Australia.
3. Barotrauma.
4. Status asthmaticus.

Unusual causes include arthroscopy, dental extraction, and adenotonsilectomy, scuba diving, trombone playing, and performing a maximal expiratory pressure maneuver.

Pneumomediastinum of a GI origin has been described in the medicalliterature. It can occur after GI instrumentation, endoscopy, endoscopic retrograde cholangiopancreatography, colonoscopy, or laparoscopic surgery. It may occur with or without evidence of perforation. In most cases, the condition is self-limited and resolves without surgical intervention, although a possible life-threatening etiology should be considered. A known life-threatening cause of pneumomediastinum is spontaneous esophageal rupture (Boerhaave’s syndrome). An esopha-gogram should, therefore, be included in the routine workup of pneumomediastinum and subcutaneous emphysema in the appropriate clinical setting.