What Lies Beneath: Sub-diaphragmatic causes of subcutaneous emphysema – A Review
Main Article Content
Abstract
Air in the subcutaneous tissues, commonly described as subcutaneous emphysema, creates a distinctive clinical sign on palpation. Usually, this results from an air leak from the airways or lungs forcing air into the mediastinum and in between soft tissue planes. This review aims to draw attention to bowel perforations below the diaphragm as an alternative origin of subcutaneous emphysema. Reference to numerous case reports illustrate a variety of presentations and causes. Delayed recognition and treatment of bowel perforation can have serious, potentially life-threatening, consequences. Patients presenting with subcutaneous emphysema without an obvious intra-thoracic cause should lead the clinician to consider acute intra-abdominal pathology, such as bowel perforation, especially after endoscopic procedures. Early recognition of this phenomenon can be life saving.
Keywords:
Subcutaneous emphysema, Bowel perforation, Sub-diaphragmatic causes, Endoscopy complications, Intra-abdominal pathology, Extra-thoracic emphysema, Case reports, Abdominal emergencies, Clinical diagnosis, Surgical complications
Article Details
How to Cite
DUNCKLEY, Matthew G.; THANT, Aung Phyo; ADAMEK, Jacek.
What Lies Beneath: Sub-diaphragmatic causes of subcutaneous emphysema – A Review.
Medical Research Archives, [S.l.], v. 13, n. 7, july 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6592>. Date accessed: 05 dec. 2025.
doi: https://doi.org/10.18103/mra.v13i7.6592.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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14. Verma R. Case report: A rare case of colonic perforation presenting as subcutaneous emphysema of lower chest, anterior abdominal wall and scrotum. Santosh Univ J Health Sci. 2015; 1:47-49.
15. Haldeniya K, Krishna SR, Raghavendra A and Kumar Singh P. Pneumomediastinum, pneumoperitoneum and pneumo-scrotum with extensive increasing subcutaneous emphysema: a rare presentation of colonic perforation. Egypt Liver J. 2023; 13:68-70.
16. Saldua NS, Fellars TA and Covey DC. Bowel perforation presenting as subcutaneous emphysema of the thigh. Clin Orthop Relat Res. 2010; 468:619-623.
17. Ioannidis O, Kakoutis E, Paraskevas G, Chatzopoulos S, Kotonis A, Papadimitriou N, Konstantara A and Makrantonakis A. Emphysematous cellulitis of the left thigh caused by sigmoid diverticulum perforation. Ann Ital Chir. 2011; 82:217-220.
18. Velickovic M and Hockertz T. Perforation of an occult carcinoma of the prostate as a rare differential diagnosis of subcutaneous emphysema of the leg. Case Reports Ortho. 2016; 10.1155/ 2016/5430637.
19. Tosi M, Al-Awa A, Raeymaeckers S and De Mey J. Subcutaneous emphysema of the extremities: Be wary of necrotising fasciitis, but also consider occult rupture or perforation. Clin Case Rep. 2021; 9:e04831.
20. Kipple J. Bilateral tension pneumothoraces and subcutaneous emphysema following colonoscopic polypectomy: A case report and discussion of anaesthesia considerations. AANA Journal. 2010; 78: 462-467.
21. Zeno BR, Sahn SA. Colonoscopy associated pneumothorax: a case of tension pneumothorax and a review of the literature. Am J Med Sci. 2006; 332:153-155.
22. Montori G, Di Giovanni G, Mzoughi Z, Angot C, Samman S, Al Solaini L and Cheynel N. Pneumoretroperitoneum and pneumomediastinum revealing a left colon perforation. Int Surg. 2015; 100:984-988.
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24. Hunt I, Van Gelderen F and Irwin R. Subcutaneous emphysema of the neck and colonic perforation. Emerg Med J. 2002; 19:465.
25. Murariu D, Tatsuno BK, Tom MK, You JS and Maldini G. Subcutaneous emphysema, pneumopericardium, pneumomediastinum and pneumoretroperitoneum secondary to sigmoid perforation: A case report. Hawai J Med Pub Health. 2012; 71:74-77.
26. Muronoi T, Kidani A, Hira E, Takeda K, Kuramoto S, Oka K, Shimojo Y and Watanabe H. Mediastinal, retroperitoneal and subcutaneous emphysema due to sigmoid colon penetration; A case report and literature review. Int J Surg Case Reports 2019; 55:213-217.
27. Riccardello GJ, Barr LK and Bassani L. Bowel perforation presenting with acute abdominal pain and subcutaneous emphysema in a 14 year old girl with an abandoned distal peritoneal shunt catheter: case report. J Neurosurg Pediatr. 2016; 18:325-328.
28. Diop S, Giabicani M and Legriel S. Colonic perforation revealed by massive subcutaneous emphysema. Int J Crit Ill Inj Sci. 2021; 11:106-108.
29. Mirzayan R, Cepkinian V, Asensio JA. Subcutaneous emphysema, pneumomediastinum, pneumothorax, pneumopericardium and pneumoperitoneum from rectal barotrauma. J Trauma. 1996;6:1073–5.
30. Lee YJ, Basu NN, Parampili U and Birch D. An unusual case of rectal perforation resulting in extensive surgical emphysema. BMJ Case Reports. 2012; 10.1136/bcr.09.2011.4822.
31. Besic N, Zgajnar J, Kocijancic I. Pneumomediastinum, pneumopericardium, and pneumoperitoneum caused by peridiverticulitis of the colon: report of a case. Dis Colon Rectum. 2004; 47:766-768.
32. Asano TK, Burns A, Pinchuk B and Shargall Y. Surgical images: An unusual presentation of perforated sigmoid colon. J Can Chir. 2008; 51: 474-475.
33. Choudhury M and Vassallo M. Cervical subcutaneous emphysema; sequelae from occult perforation of sigmoid diverticulum. Int J Clin Med. 2010; 78-80.
34. Siddiqui UT, Shahzad H and Raja AJ. Pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum and extensive subcutaneous emphysema in a patient with ulcerative colitis: A case report. Int J Surg Case Reports. 2015; 17:12-15.
35. Sahu SK, Bisht M and Sachan PK. Appendicular abscess leading to surgical emphysema of abdominal wall and thigh: A case report. J Surg Arts. 2011; 4:15-17.
36. Falconi S, Wilhelm C, Loewen J and Soliman B. Necrotizing fasciitis of the abdominal wall secondary to complicated appendicitis: A case report. Cureus. 2023; 15:e39635.
37. Ho HC, Burchell S, Morris P and Yu M. Colon perforation, bilateral pneumothoraces, pneumopericardium, pneumomediastinum, and subcutaneous emphysema complicating endoscopic polypectomy: anatomic and management considerations. Am Surg. 1996; 62:770-774.
38. Marwan K, Farmer KC, Varley C and Chapple KS. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema following diagnostic colonoscopy. Ann R Coll Surg Engl. 2007; 89: W20-W21.
39. Chan YC, Tsai YC and Fang SY. Subcutaneous emphysema, pneumothorax, pneumomediastinum, and pneumoperitoneum during colonoscopic balloon dilatation: A case report. Kaohsiung J Med Sci. 2010; 26:669-672.
40. Jung HC, Kim HJ, Ji SB, Cho JH, Kwak JH, Lee CM, Kim WS, Kim JJ, Lee JM and Lee SS. Pneumoperitoneum, pneumomediastinum, subcutaneous emphysema after a rectal endoscopic mucosal resection. Ann Coloproctol. 2016;32:234-238.
41. Bouma G, van Bodegraven AA, van Waesberghe JH, Mulder CJ and Pieters-van den Bos IC. Post-colonoscopy massive air leakage with full body involvement: An impressive complication with uneventful recovery. Am J Gastroenterol. 2009; 104: 1330-1332.
42. Falidas E, Anyfantakis G, Vlachos K, Goudeli C, Stavros B and Villias C. Pneumoperitoneum, retropneumoperitoneum, pneumomediastinum and diffuse subcutaneous emphysema following diagnostic colonoscopy. Case Reports Surg. 2012; 10.1155/2012/108791.
43. Lu A and Aronowitz P. Sigmoid perforation in association with colonoscopy. NEJM. 2012; 366:744.
44. Dehal A and Tessier DJ. Intraperitoneal and extraperitoneal colonic perforation following diagnostic colonoscopy. J Soc Laparoendosc Surg. 2014; 18: 136-141.
45. Khan M, Ijaz M, Bukhari S, Dirweesh A and Christmas D. Post-colonoscopy colonic perforation presenting with subcutaneous emphysema: A case report. Gastroenterol Res. 2017;10:135-137.
46. Jaafar S, Fong SSH, Waheed A, Misra S and Chavda K. Pneumoperitoneum with subcutaneous emphysema after a post colonoscopy colonic perforation. Int J Surg Case Rep. 2019; 58: 117-120.
47. Yang CH, Su FI, Lin CY, Liu YW and Sheen-Chen SM. Facial subcutaneous emphysema as a rare manifestation of complications after endoscopic papillary balloon dilatation. Gastrointest Endosc. 2008; 67:377-378.
48. Beintaris I, Polymeros D, Papanikolaou IS, Kontopoulou C, Kourikou A, Sioulas AD, Danias N, Dimitriadis G and Triantafyllou K. Fatal perforation with subcutaneous emphysema complicating ERCP. Endoscopy. 2012; 44:E313-E314.
49. Ferrara F, Luigiano C, Billi P, Jovine E, Cinquantini F and D’Imperio N. Pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema after ERCP. Gastrointest Endoscopy. 2009; 69:1398-1401.
50. Feret-Adrabinska W, Wojciechowski J, Skolozdrzy T, Daniel A, Gawel K and Bialek A. Subcutaneous emphysema of the lower extremity and pneumoperitoneum after endoscopic retrograde cholangiopancreatography-related duodenal perforation. Pol Arch Int Med. 2023; 133:16568.
51. Nadeem A, Husnain A, Zia MT and Ahmed A. Concurrent acute pancreatitis, pneumoperitoneum, and pneumomediastinum following ERCP-related perforation: A rare and insightful case study. Radiol Case Reports 2024; 19:1419-1423.
52. Tridente A, Clarke GM, Walden A, McKechnie S, Hutton P, Mills GH, Gordon AC, Holloway PAH, Chiche JD, Bion J, Stuber F, Garrard C, Hinds C and the GenOSept Investigators. Patients with faecal peritonitis admitted to European intensive care units: an epidemiological survey of the GenOSept cohort. Intensive Care Med. 2014; 40:202-210.
53. Hsu CW, Sun SF. Iatrogenic pneumothorax related to mechanical ventilation. World J Crit Care Med. 2014; 3:8-14.
2. Dubin I, Gelber M, Schattner A. Massive Spontaneous Subcutaneous Emphysema. Am J Med. 2016; 129:e337–8.
3. Melhorn J and Davies HE. The management of subcutaneous emphysema in pneumothorax: A literature review. Curr Pulmonol Reports. 2021; 10:92–97.
4. Jones P, Hewer RD, Wolfenden HD, Thomas PS. Subcutaneous emphysema associated with chest tube drainage. Respirology. 2001; 6:87–9.
5. Gimenez A, Tomás Franquet T, Jeremy J. Erasmus JJ, Santiago Martínez S, Estrada P. Thoracic complications of esophageal disorders. Radiographics. 2002; 22: S247-58.
6. Maunder RJ, Pierson DJ and Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis and management. Arch Intern Med. 1984; 144:1447-53.
7. Abdalla S, Gill R, Yusuf GT and Scarpinata R. Anatomical and radiological considerations when colonic perforation leads to subcutaneous emphysema, pneumothoraces, pneumomediastinum and mediastinal shift. Surg J 2018; 4:e7-e13.
8. Catarino PA and Smith EE. Subcutaneous emphysema of the thorax heralding colonic perforation. Ann Thorac Surg. 2001; 71:1341-1343.
9. Janczak D, Ziomek A, Dorobisz T, Dorobisz K, Janczak D, Pawlowski W and Chabowski M. Subcutaneous emphysema of the neck, chest and abdomen as a symptom of colonic diverticular perforation into the retroperitoneum. Kardiochir Torakochir Polska. 2016; 13:55-57.
10. Schmidt GB, Bronkhorst MW, Hartgrink HH and Bouwman LH. Subcutaneous cervical emphysema and pneumomediastinum due to a lower gastrointestinal perforation. World J Gastroent. 2008; 14:3922-3923.
11. Hartford-Beynon JS, Kadambande S and Rassam S. Surgical emphysema of the orbit associated with pneumoperitoneum. Br J Anaesth 2011; 105:151.
12. Bormann SL, Wood R and Guido JM. Hoarseness due to subcutaneous emphysema: a rare presentation of diverticular perforation. J Surg Case Rep. 2024; 10.1093/jscr/rjad566.
13. Fosi S, Giuricin V, Girardi V, Di Caprera E, Cosatanzo E, Di Trapano R and Simonetti G. Subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum and pneumoscrotum: Unusual complications of acute perforated diverticulitis. Case Reports Radiol. 2014; 10.1155/2014/431563.
14. Verma R. Case report: A rare case of colonic perforation presenting as subcutaneous emphysema of lower chest, anterior abdominal wall and scrotum. Santosh Univ J Health Sci. 2015; 1:47-49.
15. Haldeniya K, Krishna SR, Raghavendra A and Kumar Singh P. Pneumomediastinum, pneumoperitoneum and pneumo-scrotum with extensive increasing subcutaneous emphysema: a rare presentation of colonic perforation. Egypt Liver J. 2023; 13:68-70.
16. Saldua NS, Fellars TA and Covey DC. Bowel perforation presenting as subcutaneous emphysema of the thigh. Clin Orthop Relat Res. 2010; 468:619-623.
17. Ioannidis O, Kakoutis E, Paraskevas G, Chatzopoulos S, Kotonis A, Papadimitriou N, Konstantara A and Makrantonakis A. Emphysematous cellulitis of the left thigh caused by sigmoid diverticulum perforation. Ann Ital Chir. 2011; 82:217-220.
18. Velickovic M and Hockertz T. Perforation of an occult carcinoma of the prostate as a rare differential diagnosis of subcutaneous emphysema of the leg. Case Reports Ortho. 2016; 10.1155/ 2016/5430637.
19. Tosi M, Al-Awa A, Raeymaeckers S and De Mey J. Subcutaneous emphysema of the extremities: Be wary of necrotising fasciitis, but also consider occult rupture or perforation. Clin Case Rep. 2021; 9:e04831.
20. Kipple J. Bilateral tension pneumothoraces and subcutaneous emphysema following colonoscopic polypectomy: A case report and discussion of anaesthesia considerations. AANA Journal. 2010; 78: 462-467.
21. Zeno BR, Sahn SA. Colonoscopy associated pneumothorax: a case of tension pneumothorax and a review of the literature. Am J Med Sci. 2006; 332:153-155.
22. Montori G, Di Giovanni G, Mzoughi Z, Angot C, Samman S, Al Solaini L and Cheynel N. Pneumoretroperitoneum and pneumomediastinum revealing a left colon perforation. Int Surg. 2015; 100:984-988.
23. Kuhn G, Lekeufack JB, Chilcott M and Mbaidjol Z. Subcutaneous emphysema caused by an extraperitoneal diverticulum perforation: description of two rare cases and review of the literature. Case Reports Surg. 2018; Article ID 3030869.
24. Hunt I, Van Gelderen F and Irwin R. Subcutaneous emphysema of the neck and colonic perforation. Emerg Med J. 2002; 19:465.
25. Murariu D, Tatsuno BK, Tom MK, You JS and Maldini G. Subcutaneous emphysema, pneumopericardium, pneumomediastinum and pneumoretroperitoneum secondary to sigmoid perforation: A case report. Hawai J Med Pub Health. 2012; 71:74-77.
26. Muronoi T, Kidani A, Hira E, Takeda K, Kuramoto S, Oka K, Shimojo Y and Watanabe H. Mediastinal, retroperitoneal and subcutaneous emphysema due to sigmoid colon penetration; A case report and literature review. Int J Surg Case Reports 2019; 55:213-217.
27. Riccardello GJ, Barr LK and Bassani L. Bowel perforation presenting with acute abdominal pain and subcutaneous emphysema in a 14 year old girl with an abandoned distal peritoneal shunt catheter: case report. J Neurosurg Pediatr. 2016; 18:325-328.
28. Diop S, Giabicani M and Legriel S. Colonic perforation revealed by massive subcutaneous emphysema. Int J Crit Ill Inj Sci. 2021; 11:106-108.
29. Mirzayan R, Cepkinian V, Asensio JA. Subcutaneous emphysema, pneumomediastinum, pneumothorax, pneumopericardium and pneumoperitoneum from rectal barotrauma. J Trauma. 1996;6:1073–5.
30. Lee YJ, Basu NN, Parampili U and Birch D. An unusual case of rectal perforation resulting in extensive surgical emphysema. BMJ Case Reports. 2012; 10.1136/bcr.09.2011.4822.
31. Besic N, Zgajnar J, Kocijancic I. Pneumomediastinum, pneumopericardium, and pneumoperitoneum caused by peridiverticulitis of the colon: report of a case. Dis Colon Rectum. 2004; 47:766-768.
32. Asano TK, Burns A, Pinchuk B and Shargall Y. Surgical images: An unusual presentation of perforated sigmoid colon. J Can Chir. 2008; 51: 474-475.
33. Choudhury M and Vassallo M. Cervical subcutaneous emphysema; sequelae from occult perforation of sigmoid diverticulum. Int J Clin Med. 2010; 78-80.
34. Siddiqui UT, Shahzad H and Raja AJ. Pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum and extensive subcutaneous emphysema in a patient with ulcerative colitis: A case report. Int J Surg Case Reports. 2015; 17:12-15.
35. Sahu SK, Bisht M and Sachan PK. Appendicular abscess leading to surgical emphysema of abdominal wall and thigh: A case report. J Surg Arts. 2011; 4:15-17.
36. Falconi S, Wilhelm C, Loewen J and Soliman B. Necrotizing fasciitis of the abdominal wall secondary to complicated appendicitis: A case report. Cureus. 2023; 15:e39635.
37. Ho HC, Burchell S, Morris P and Yu M. Colon perforation, bilateral pneumothoraces, pneumopericardium, pneumomediastinum, and subcutaneous emphysema complicating endoscopic polypectomy: anatomic and management considerations. Am Surg. 1996; 62:770-774.
38. Marwan K, Farmer KC, Varley C and Chapple KS. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema following diagnostic colonoscopy. Ann R Coll Surg Engl. 2007; 89: W20-W21.
39. Chan YC, Tsai YC and Fang SY. Subcutaneous emphysema, pneumothorax, pneumomediastinum, and pneumoperitoneum during colonoscopic balloon dilatation: A case report. Kaohsiung J Med Sci. 2010; 26:669-672.
40. Jung HC, Kim HJ, Ji SB, Cho JH, Kwak JH, Lee CM, Kim WS, Kim JJ, Lee JM and Lee SS. Pneumoperitoneum, pneumomediastinum, subcutaneous emphysema after a rectal endoscopic mucosal resection. Ann Coloproctol. 2016;32:234-238.
41. Bouma G, van Bodegraven AA, van Waesberghe JH, Mulder CJ and Pieters-van den Bos IC. Post-colonoscopy massive air leakage with full body involvement: An impressive complication with uneventful recovery. Am J Gastroenterol. 2009; 104: 1330-1332.
42. Falidas E, Anyfantakis G, Vlachos K, Goudeli C, Stavros B and Villias C. Pneumoperitoneum, retropneumoperitoneum, pneumomediastinum and diffuse subcutaneous emphysema following diagnostic colonoscopy. Case Reports Surg. 2012; 10.1155/2012/108791.
43. Lu A and Aronowitz P. Sigmoid perforation in association with colonoscopy. NEJM. 2012; 366:744.
44. Dehal A and Tessier DJ. Intraperitoneal and extraperitoneal colonic perforation following diagnostic colonoscopy. J Soc Laparoendosc Surg. 2014; 18: 136-141.
45. Khan M, Ijaz M, Bukhari S, Dirweesh A and Christmas D. Post-colonoscopy colonic perforation presenting with subcutaneous emphysema: A case report. Gastroenterol Res. 2017;10:135-137.
46. Jaafar S, Fong SSH, Waheed A, Misra S and Chavda K. Pneumoperitoneum with subcutaneous emphysema after a post colonoscopy colonic perforation. Int J Surg Case Rep. 2019; 58: 117-120.
47. Yang CH, Su FI, Lin CY, Liu YW and Sheen-Chen SM. Facial subcutaneous emphysema as a rare manifestation of complications after endoscopic papillary balloon dilatation. Gastrointest Endosc. 2008; 67:377-378.
48. Beintaris I, Polymeros D, Papanikolaou IS, Kontopoulou C, Kourikou A, Sioulas AD, Danias N, Dimitriadis G and Triantafyllou K. Fatal perforation with subcutaneous emphysema complicating ERCP. Endoscopy. 2012; 44:E313-E314.
49. Ferrara F, Luigiano C, Billi P, Jovine E, Cinquantini F and D’Imperio N. Pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema after ERCP. Gastrointest Endoscopy. 2009; 69:1398-1401.
50. Feret-Adrabinska W, Wojciechowski J, Skolozdrzy T, Daniel A, Gawel K and Bialek A. Subcutaneous emphysema of the lower extremity and pneumoperitoneum after endoscopic retrograde cholangiopancreatography-related duodenal perforation. Pol Arch Int Med. 2023; 133:16568.
51. Nadeem A, Husnain A, Zia MT and Ahmed A. Concurrent acute pancreatitis, pneumoperitoneum, and pneumomediastinum following ERCP-related perforation: A rare and insightful case study. Radiol Case Reports 2024; 19:1419-1423.
52. Tridente A, Clarke GM, Walden A, McKechnie S, Hutton P, Mills GH, Gordon AC, Holloway PAH, Chiche JD, Bion J, Stuber F, Garrard C, Hinds C and the GenOSept Investigators. Patients with faecal peritonitis admitted to European intensive care units: an epidemiological survey of the GenOSept cohort. Intensive Care Med. 2014; 40:202-210.
53. Hsu CW, Sun SF. Iatrogenic pneumothorax related to mechanical ventilation. World J Crit Care Med. 2014; 3:8-14.