'Ulcerative crepitus' - A case with subcutaneous emphysema and pneumomediastinum without colonic perforation or toxic megacolon in ulcerative colitis successfully treated conservatively

摘要

A 19-year-old man with a 1-year history of ulcerative colitis presented with fever, bloody diarrhea and severe dehidration. He was on . po.48. mg methylprednisolon and 3. g mesalazine daily, and has recently finished taking chlarythromycin for . Campylobacter jejuni infection. On physical examination, no abdominal tenderness was found, but surprisingly, extensive bilateral subcutaneous emphysema was detected in the supraclavicular regions. Laboratory tests proved anaemia, elevated white blood cell count, thrombocyte count and CRP levels. Stool culture was negative. Chest X-ray and CT scan revealed pneumomediastinum and subcutaneous air on the neck spreading to the scapular regions. Besides blood transfusion, . iv. cyclosporin therapy was initiated (200. mg/day) along with . iv. methylprednisolon (1. mg/kg/day) and . iv. ceftriaxon (2. g/day). Stool frequency and bloody stools decreased remarkably within one week, and subcutaneous emphysema has resolved. Colonoscopy one week later revealed deep, extensive ulcerations in the transverse and descending colon without any sign of previous perforation. Cyclosporin and methylprednisolon was continued orally.Pneumomediastinum and subcutaneous emphysema in ulcerative colitis are unusual complications, typically linked to retroperitoneal colonic perforation or toxic megacolon, and are extremely rare without preceding endoscopic procedures. Except from two cases in the literature, conservative treatment with . iv. antibiotics and steroids failed to save from urgent surgical procedure, resulting in a partial or total colectomy. In our case we were able to avoid urgent surgery by the immediate use of . iv. cyclosporin in combination with . iv. steroids and antibiotics, while the outcome of the bowel remains questionable in the next few months.