A Rare Case Of Synchronous Sigmoid Perforation And Jejunum Perforation

A Rare Case Of Synchronous Sigmoid Perforation And Jejunum Perforation

Corresponding author: Dr. Hsin-Hung Chen, Division of General surgery, Department of Surgery,Taoyuan Armed Forces General Hospi- tal, Taiwan, No. 168, Zhongxing Road, Longtan Dist, Taoyuan City, Taiwan. Tel : +886-3-4799595 ; E-mail : jordan721102@gmail.com Received: 06-02-2018

Abstract

Hollow organ perforation initially presents as peritonitis but may easily progress to septic shock, which has a very high mortality rate. Elapsed time to surgery has been identified as the most important prognostic factor for hollow organ perforation, due to the risk of peritonitis. Colon perforation is not rare and it is the most common cause of diverticulitis with perforation. However, cases of spontaneous small intestine perforation are rare, especially if there is no history of trauma. This paper presents a case of a 92-year-old male suffering from jejunum perforation synchronously with sigmoid perforation.

Keywords: Pcolon perforation; pneumo peritoneum; jejunum perforation 

Introduction

The mortality rate for hollow organ perforation can be at- tributed to the ease with which it progresses to peritonitis with septic shock. This paper describes one clinical case of je- junum perforation occurring synchronously with sigmoid per- foration and acute peritonitis. In the following, we discuss the clinical manifestations, radiological findings, and management of hollow organ perforation.

Case Report

A 92-year-old male presented at our emergency department complaining of abdominal pain and impaired consciousness since that morning. The patient described a cerebellar vascu- lar accident in the past. The patient’s vital signs were as fol- lows: blood pressure = 83/49 mmHg, pulse rate = 139 beats per minute, and body temperature = 35.5C Blood tests per- formed at the time of admission revealed a white cell count of 9100 10*3/µl, hemoglobin of 12.3 g/dl, band form neutrophil of 12%, and a creatinine level of 1.8 mg/dl, indicating acute kidney injury.

A physical examination also revealed guarding, tenderness, and rigidity of the abdomen. Under the impression of acute abdomen, computer tomography (CT) of the abdomen was performed, which identified pneumo peritoneum with ascites. Hollow organ perforation was strongly suspected. An emer- gency diagnostic laparoscopy, performed after communicating with the patient’s family, revealed turbid ascites as well as a perforation of the sigmoid approximately 2 cm in size. Perfo- rated diverticulitis was suspected. Hartman’s procedure was conducted during a mini-laparotomy, whereupon the entire small bowel was removed for examination. A 1-cm hole was observed over the jejunum below the ligament of Treitz; there- fore, primary suturing was performed. Following surgery, the patient was admitted to the ICU, during which piperacillin-ta- zobactam was administered. At 5 days post-surgery, the pa- tient began the oral intake of water before progressing to a full diet. No infection developed and the patient was discharged after being hospitalized for 27 days The final pathology report was chronic ulcer with perforation. No Crohn’s disease, celiac disease and lymphoma was found. Lab data showed no im- mune abnormality and no infectious disease.

Discussion

Cases of perforation over the jejunum synchronous with sig- moid perforation are very rare. Among patients with sigmoid diverticulosis, 10 to 25 percent develop acute diverticulitis with severe complications, such as fecal peritonitis, perfora- tion, and/or abscess formation [1,2].

Spontaneous small bowel perforation is uncommon. The list of possible known causes includes immune-mediated or inflam- matory conditions (e.g., Crohn’s disease), viral infections (e.g., Cytomegalovirus), drugs and biological agents (e.g., indometh- acin), malignant causes and congenital problems (e.g., Meck- el’s diverticulum). The clinical attention may be focused on other small intestinal disorders, such as Crohn’s disease and glute-sensitive enteropathy. However, the patient”s family told us that the patient was no Crohn’s disease and glute-sensitive enteropathy were diagnosed before. [3]

Clinical manifestations of hollow organ perforation include re- bounding pain over the abdomen, abdomen muscular guard- ing, or shock. Chest X-rays may reveal free air over the sub- phrenic region, whereas CT scans of the abdomen may indicate free air and/or fluid collecting in the Morrison pouch, splenic fossa, or pelvic cavity

Hinchey’s classifications may be used to assess peritoneal con- tamination intraoperatively. There are four stages: pericolic or mesenteric abscess (Stage I), walled-off pelvic abscess (Stage II), generalized purulent peritonitis (Stage III), and general- ized fecal peritonitis (Stage IV) [4].

Removing the source of infection is the most important pro- cedure in the treatment of hollow perforation, due to the high risk of mortality from fecal peritonitis [5,6]. Emergency sur- gery with resection of the affected bowel is equally important. Nonetheless, even when a perforation site has been identified, the entire abdominal cavity must be examined carefully for other problems. The case is really rare, it teached us that we could performed more lab test and try to find the really reason.

Figure 2. Peforation over jejunum (approximately 1 cm in size)

Figure 1. CT scan of the abdomen showing pneumoperitone- um

References

  1. Chapman J, Davies M, Wolff B. Complicated diverticulitis: is it time to rethink rules? Ann Surg. 2005, 242(2): 576-581.
  2. Schwesinger WH, Page CP, Gaskill HV. Operative manage- ment of diverticular emergencies: strategies and outcomes. Arch Surg. 2000, 135(5): 558-562.
  3. Hugh James Freeman. Spontaneous free perforation of the small intestine in adults. World J Gastroenterol. 2014, 20(29): 9990-9997.
  4. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978,12: 85-109.
  5. Sarin S, Boulos PB. Long-term outcome of patients present- ing with acute complications of diverticular disease. Ann R Coll Surg Engl. 1994, 76(2): 117-120.
  6. Constantinides VA, Tekkis PP, Senapati A. Association of Col- oproctology of Great Britain Ireland Prospective multicentre evaluation of adverse outcomes following treatment compli- cated diverticular disease. Br J Surg. 2006, 93(12): 1503-1513.

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