A CASE OF TENSION PNEUMOPERITONEUM DUE TO COLONIC BAROTRAUMA WITH COMPRESSED AIR

CASE REPORT: A 23 year old male working in a biscuit factory was brought to emergency department by the coworkers at 4PM with pain abdomen and distension and bleeding per rectum. On further questioning the patient confessed that his co-workers had held him firmly and directed the stream of air from a compressed-air pipeline towards his anal region in the morning. On examination, he was alerting conscious and oriented and tachypneic. The respiratory rate was 30/min, SPO280%, Pulse was 120/min and B.P. 120/80 mm Hg. On palpation, Abdomen was grossly distended (Fig. 1), tense with generalized tenderness and rigidity of abdominal wall. The percussion note was tympanitic and liver dullness obliterated. No free fluid was detected. Bowel sounds were absent. Examination of the perineum did not show any external injury. Rectal examination showed faeces mixed with fresh blood but did not reveal any laceration or perforation in the anal canal or rectum. Straight X-ray abdomen in erect position showed extensive pneumoperitoneum (Fig. 2) Abdominal decompression was made in view of tension pneumoperitoneum, low saturation and tachypnea. A 20G needle was inserted in the right upper quadrant just lateral to rectus abdominis muscle following which the pneumoperitoneum reduced with sudden improvement in the oxygen saturation (98%) and tachypnea got reduced. A clinical diagnosis of pneumatic rupture of hollow viscera, probably colon was made. An emergency exploratory laparotomy under general anesthesia through a mid-midline incision was carried out. Intraoperative, a single perforation of 3x2cms in the ant mesenteric border of transverse colon 15cms away from the hepatic flexure (Fig. 3) with fecal spillage into the peritoneal cavity was noted. There was also sero muscular tear along the entire length of the transverse colon (Fig. 4) and extensive contusions around the entire colon. Thorough visceral inspection of abdomen did not reveal any other visceral injury. The perforation was closed in two layers using 2-0 vicryl and 2-0 silk and the areas of serosal tears were sutured using 2-0 silk. After a thorough peritoneal lavage, a de functioning transverse loop colostomy was placed in the right upper quadrant and the wound was closed in layers with an abdominal drain. Postoperative recovery was quite uneventful and colostomy reversal is planned later.