What are the potential causes of acute pleuritic chest pain in a patient after undergoing colonoscopy?

Acute Pleuritic Chest Pain After Colonoscopy

The most critical concern is iatrogenic colonic perforation, which can present with pleuritic chest pain due to pneumomediastinum, pneumothorax, or subcutaneous emphysema—even in the absence of abdominal pain—and requires immediate CT imaging and surgical consultation. 1, 2, 3

Immediate Life-Threatening Causes to Rule Out

Iatrogenic Colonoscopy Perforation

• Colonic perforation can present with chest pain as the primary symptom, occurring through retroperitoneal gas tracking into the mediastinum and pleural space 2, 3, 4
• Perforation should be suspected in any patient with abdominal pain, tenderness, abdominal distension, fever, and/or rectal bleeding after colonoscopy, but atypical presentations with isolated chest symptoms occur 1
• CT scan is the most accurate imaging tool to diagnose perforation, showing pneumomediastinum, pneumoretroperitoneum, pneumothorax, and subcutaneous emphysema 1, 2, 3
• Patients may present with hoarseness, throat pain, neck swelling, voice changes, and pleuritic chest pain without abdominal symptoms 3, 4
• Diverticular disease increases perforation risk during colonoscopy, particularly in the sigmoid colon 2

Pulmonary Embolism

• PE is the most common life-threatening cause of pleuritic pain, found in 5-21% of patients presenting with this symptom 5, 6
• Presents with dyspnea (80% of cases), pleuritic chest pain (52%), tachycardia (>90%), and tachypnea (70%) 7, 8
• Colonoscopy itself is a risk factor for PE due to immobilization and the procedure itself 7
• Use validated clinical decision rules to determine pretest probability, followed by D-dimer or CT pulmonary angiography 7, 9

Cardiac Causes

• 13% of patients with pleuritic pain have acute myocardial ischemia, and sharp pleuritic features do not exclude cardiac disease 7, 9
• ECG should be obtained within 10 minutes and cardiac troponin measured immediately 9
• Pericarditis presents with sharp, pleuritic pain that improves sitting forward, with widespread ST-elevation and PR depression on ECG 7

Pneumothorax

• Can occur as a complication of colonic perforation with gas tracking into the pleural space 2, 3
• Presents with dyspnea, pleuritic pain, and unilateral decreased breath sounds 7, 9

Diagnostic Algorithm

Immediate Assessment (Within Minutes)

• Vital signs: Tachycardia and tachypnea present in >90% of PE cases; hypotension suggests high-risk PE or sepsis from perforation 7, 8
• ECG within 10 minutes to identify STEMI, pericarditis patterns, or signs of PE 9
• Cardiac troponin measured immediately to exclude myocardial injury 9

First-Line Imaging (Within 1 Hour)

• Chest X-ray (PA and lateral) to evaluate for pneumothorax, pneumomediastinum, subcutaneous emphysema, pneumonia, or pleural effusion 7, 9, 2
• CT scan of chest and abdomen with IV contrast if perforation suspected based on clinical presentation or chest X-ray findings 1, 2, 3

Risk Stratification for PE

• Assess for immobilization (colonoscopy procedure itself), history of DVT/PE, malignancy, recent surgery 7
• Apply validated clinical decision rules for PE probability 7, 9
• D-dimer with age-adjusted cutoffs for low-to-intermediate probability patients 9
• CT pulmonary angiography for high clinical suspicion or positive D-dimer 7, 9

Physical Examination Findings

Signs of Perforation with Gas Tracking

• Subcutaneous emphysema in neck or chest wall (crepitus on palpation) 2, 3, 4
• Hoarseness or voice changes from mediastinal gas 3, 4
• Neck swelling or throat pain 3, 4
• Abdominal tenderness may be absent in retroperitoneal perforations 2, 3

Pleural Findings

• Pleural friction rub: biphasic, coarse, grating sound during both inspiration and expiration, not cleared by coughing, indicates pleural inflammation 7, 9
• Unilateral decreased breath sounds suggest pneumothorax or large effusion 9

Cardiac Findings

• Pericardial friction rub suggests pericarditis 9
• Reproducible chest wall tenderness suggests musculoskeletal cause, but 7% of patients with reproducible tenderness still have acute coronary syndrome 7, 9

Management Based on Diagnosis

Confirmed or Suspected Perforation

• Immediate surgical consultation and multidisciplinary team involvement (gastroenterologist, surgeon, anesthesiologist) 1
• Early surgery within 24 hours if signs of peritoneal contamination, sepsis, or hemodynamic instability 1
• Endoscopic closure may be attempted for small perforations detected immediately, in hemodynamically stable patients without sepsis 1
• Conservative management (bowel rest, IV hydration, broad-spectrum antibiotics for 3-5 days) only for small perforations, absence of sepsis, correct bowel preparation, and asymptomatic or improving symptoms 1
• Close monitoring is essential as early improvement does not rule out need for surgery 1

Pulmonary Embolism

• Anticoagulation based on risk stratification 8
• Hemodynamic support for high-risk PE 8

Other Causes

• Empyema requires drainage and antibiotics 9
• Pneumothorax management depends on size and clinical stability 9
• Pericarditis treated with NSAIDs and colchicine 7

Critical Pitfalls to Avoid

• Never assume absence of abdominal pain excludes perforation—chest symptoms may be the only manifestation 2, 3, 4
• Do not delay CT imaging if perforation is suspected based on chest X-ray findings of pneumomediastinum or subcutaneous emphysema 1, 2
• Reproducible chest wall tenderness does not exclude serious pathology (7% have ACS) 7, 9
• Nearly half of PE patients have no chest pain, so absence of pain does not exclude PE 8
• Normal oxygen saturation does not exclude PE (20% of PE patients have normal arterial oxygen pressure) 8
• Sharp, pleuritic features do not exclude cardiac ischemia 7, 9