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CASE REPORT
Year : 2018  |  Volume : 32  |  Issue : 1  |  Page : 66-68

Iatrogenic fecopneumothorax: A rare cause of hydropneumothorax


1 Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
2 Department of Pulmonary Medicine, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India

Date of Web Publication18-Jun-2018

Correspondence Address:
Dr. Hemant Kumar
Department of Pulmonary Medicine, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi - 110 070
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_92_16

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  Abstract 

Fecopneumothorax is an unusual and uncommon cause of hydropneumothorax. It is an extremely rare pleural disease, with only 16 cases being reported from worldwide. Here we report, a 35-year-old, previously healthy man with an incidental Bochdalek hernia whose chest radiograph was misinterpreted as hydropneumothorax and managed by an intercostal chest drain. This leads to a left colopleural fistula and fecopneumothorax. The patient was managed surgically and recovered well. To the best of our knowledge, this is the first case of fecopneumothorax which is iatrogenic in nature.

Keywords: Bochdalek hernia, colopleural fistula, fecopneumothorax, hydropneumothorax


How to cite this article:
Kumar H, Periwal P, Jain A, Jain S, Yadav S, Jain A, Chawla A. Iatrogenic fecopneumothorax: A rare cause of hydropneumothorax. J Med Soc 2018;32:66-8

How to cite this URL:
Kumar H, Periwal P, Jain A, Jain S, Yadav S, Jain A, Chawla A. Iatrogenic fecopneumothorax: A rare cause of hydropneumothorax. J Med Soc [serial online] 2018 [cited 2020 May 25];32:66-8. Available from: http://www.jmedsoc.org/text.asp?2018/32/1/66/214736


  Introduction Top


Fecopneumothorax is an extremely rare pleural disease. Most patients present after a blunt or penetrating trauma, surgical procedure, or colonic malignancy. We present a young man with left-sided iatrogenic colopleural fistula resulting in a fecopneumothorax. To the best of our knowledge, this is the first case of fecopneumothorax which is iatrogenic in nature.


  Case Report Top


A 35-year-old smoker, presented with a dry cough, fever, and progressively worsening breathlessness for the past 1 week to a local physician. He also complained of left-sided abdominal pain and constipation for the same duration. He was evaluated and his laboratory parameters were found to be within normal limits. A chest skiagram [Figure 1] was obtained, and a diagnosis of left-sided hydropneumothorax was made. In view of respiratory distress and chest X-ray finding, a left-sided intercostal chest drain (ICD) was inserted, and he was started on broad spectrum antibiotics. However, there was no improvement in his symptoms, and he was referred to us.
Figure 1: Chest X-ray: Multiple air-fluid level on the left side

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The patient had no recent history of trauma and no previous history of any chronic medical illness or surgical intervention.

On examination, he was febrile (Tmax-100F) with heart rate: 102/min, blood pressure: 100/70 mmHg, respiratory rate: 26/min and SpO298% on room air. General physical examination was grossly normal and respiratory system examination revealed left-sided ICD in situ draining foul smelling turbid fluid and reduced breath sound over the left hemithorax.

Blood investigations showed: Hb 12 gm/dl, total leukocyte count 6900, platelet count 222,000 cumm, serum urea 58 mg/dl, serum creatinine 0.8 mg/dl, serum sodium 134 meq/L, serum potassium 3.5 meq/L, serum bilirubin 0.8 mg/dl, serum glutamic oxaloacetic transaminase 45U/L, and serum glutamic-pyruvic transaminase 65U/L. A chest radiograph [Figure 2] was obtained, and it showed left-sided massive hydropneumothorax with left-sided ICD in situ. The ICD fluid was foul smelling and we noticed a rapidly filling ICD bottle following patient's meals. The draining fluid was feculent in nature. In view of the clinical history, nature of the ICD fluid and radiological findings a provisional diagnosis of left fecopneumothorax was made. Surgical consultation was sought and computed tomography (CT) thorax and abdomen were obtained. CT [Figure 3] and [Figure 4] depicted left side diaphragmatic hernia (Bochdalek type), herniation of large bowel and omentum into the left hemithorax through the diaphragmatic defect, colopleural fistula, and gross left hydropneumothorax causing a significant mediastinal mass effect. The patient underwent immediate exploratory laparotomy and thoracotomy with resection of the splenic flexure with primary colo-colic anastomosis with proximal diverting ileostomy with primary repair of diaphragmatic hernia on the left side and pleural drainage.
Figure 2: Chest X-ray: Massive hydropneumothorax with mediastinal shift to the right. Left-sided intercostal chest drain in situ

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Figure 3: Computed tomography thorax and abdomen: Left side diaphragmatic hernia (Bochdalek type), herniation of large bowel and omentum into the left hemithorax though the diaphragmatic defect

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Figure 4: Computed tomography thorax and abdomen: Colopleural fistula and left gross hydropneumothorax causing significant mediastinal mass effect

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Intraoperative findings confirmed a left diaphragmatic (posterolateral) hernia with spleen, transverse colon, and splenic flexure as content. There was rent in the splenic flexure and fecal contamination of the pleural cavity. The underlying left lung was collapsed.

Postoperative serial chest X-rays [Figure 5] showed left lung expansion and the ICD was removed. The patient was discharged on the 25th postoperative day and continues to do well. A final diagnosis of iatrogenic left fecopneumothorax with colopleural fistula and left Bochdalek hernia was made.
Figure 5: X-ray: Postopertative chest X-ray with resolving hydropneumothorax with intercostal chest drain in situ

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  Discussion Top


Fecopneumothorax is an extremely rare disease entity. Extensive literature search shows, there are only 16 such cases reported from around the world due to all causes. To the best of our knowledge, this is the first case of iatrogenic fecopneumothorax being reported.

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.[1]

Most reported cases from worldwide suggest trauma to be the most common cause. Other rarely reported causes include strangulated hernia loops, malignancy, Crohn's disease, and postesophagectomy.[1],[2],[3],[4],[5] Our patient was previously healthy, with no history of recent or past trauma or medical illness.

Depending on the etiology, the patients usually present with respiratory distress, tachycardia, tachypnea, and hypoxia.[4] Examination reveals decreased breath sound over the affected hemithorax.[4] On presentation to us, our patient had an ICD in situ, probably subverting respiratory distress.

Diagnosis is based on thorough clinical examination and imaging studies including chest X-rays, barium studies, CT thorax, and abdomen. Chest X-rays demonstrate an elevated hemidiaphgram with bowel loop in the chest.[1] Barium studies depict the colopleural fistula with contrast leaking into the pleural cavity.[4] CT thorax and abdomen are more accurate and aid surgical planning.[4]

There is no role of conservative management and treatment is surgical.

Bochdalek hernia is usually asymptomatic and incidental in nature.[6] Our patient probably presented to the local physician with a lower respiratory tract infection. The chest X-ray obtained at that point depicted a diaphragmatic hernia with bowel loop in the left hemithorax suggesting an incidental Bochdalek hernia. This chest radiograph was misinterpreted as a hydropneumothorax, and an ICD was inserted for the same.

Important clinical lessons from this case are: (A) In case of left-sided hydropneumothorax, always look for the gastric bubble shadow. An absent gastric fundic shadow should alert the physician to additionally look for diaphragmatic hernia before inserting the ICD. (B) In rapidly refilling pleural effusions following a meal, the possibility of colopleural fistula cannot be ruled out and should be promptly investigated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kelly J, Condon E, Kirwan W, Redmond H. Post-traumatic tension faecopneumothorax in a young male: Case report. World J Emerg Surg 2008;3:20.  Back to cited text no. 1
[PUBMED]    
2.
Popentiu AI, Weber-Lauer C, Nieman C, Kauvar DS, Sabau D. Late presentation of a shrapnel wound-induced traumatic intra-thoracic abdominal evisceration, as colon perforation with left faecopneumothorax. Chirurgia (Bucur) 2010;105:253-6.  Back to cited text no. 2
[PUBMED]    
3.
Tabbara M, Nencioni M, Carandina S. Left colon cancer presenting as fecopneumothorax: A case report and review of literature. Int J Colorectal Dis 2015;30:275-6.  Back to cited text no. 3
[PUBMED]    
4.
Barisiae G, Krivokapiae Z, Adziae T, Pavloviae A, Popoviae M, Gojniae M. Fecopneumothorax and colopleural fistula - Uncommon complications of Crohn's disease. BMC Gastroenterol 2006;6:17.  Back to cited text no. 4
[PUBMED]    
5.
Markogiannakis H, Theodorou D, Tzertzemelis D, Dardamanis D, Toutouzas KG, Misthos P, et al. Fecopneumothorax: A rare complication of esophagectomy. Ann Thorac Surg 2007;84:651-2.  Back to cited text no. 5
[PUBMED]    
6.
Hamid KS, Rai SS, Rodriguez JA. Symptomatic Bochdalek hernia in an adult. JSLS 2010;14:279-81.  Back to cited text no. 6
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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