Colon perforation is characterized by a high mortality rate because the condition can easily progress to peritonitis with septic shock. In this report, we describe one clinical case of cecal diverticulitis and adenocarcinoma with perforation and peritonitis. We further discuss the clinical manifestations, radiological findings, and management of colon perforation.
A 79-year-old male presented to the emergency department after suffering from abdominal pain for 3 days and tarry stool for 2 days. The patient had a past history of asthma and type II diabetes mellitus. His blood pressure was 145/92mmHg; his pulse was 72 beats per minute; and his body temperature was 36.5 o C. A blood test conducted at the time of admission further showed that the patient had a white blood cell count of 10300, a hemoglobin count of 10.5, a band form neutrophil level of 38%, and an acute kidney injury with a creatinine level of 3.15.
Abdomen physical examination revealed abdominal guarding, tenderness, and rigidity of the abdomen. Under the impression of surgical abdomen, abdomen computer tomography was performed, and pneumoperitoneum was found. Hollow organ perforation was highly suspected. After the patient communicated with his family, we arranged for emergent exploratory laparotomy to be performed. During the surgical procedure, perforation of the cecum was found. Initially, a perforated diverticulum was suspected; however, a mass lesion was noted over the peri-perforation region. A colonrectal specialist was therefore consulted, who suspected cecum cancer. We thus performed exploratory laparotomy with segmental resection of the cecum and anastomosis of the ascending colon and terminal ileum. The patient was transferred to an intensive care unit following surgery. After his condition stabilized, the patient was discharged and followed up by the hospital out-patient department.
Colon perforation due to diverticulitis and colon cancer is uncommon. Among patients with sigmoid diverticulosis, between 10 and 25% will develop acute diverticulitis with complications . Severe complications of acute diverticulitis include feculent peritonitis, colon perforation, and/or abscess formation .The patient that we discussed is cecal diverticulitis with perforation and peritonitis. A mass lesion was noted over the peri-perforation region accidentally. The final pathological report is colon acute diverticulitis with chronic ulcer with perforation. Tumor pathological TNM stage is pT3NOMx.
Clinical manifestations of colon perforation include abdomen tenderness, abdomen muscle guarding, or shock. A chest X-ray may reveal the presence of free air over the subphrenic region, and abdomen computer tomography may indicate that free air and fluid has collected in the peritoneal cavity
Hinchey’s classification can be used to assess peritoneal contamination intraoperatively. This classification system divides diverticulitis into four stages. Stage I is charterized by a pericolic or mesenteric abscess; stage II is characterized by a walled-off pelvic abscess; stage III is characterized by generalized purulent peritonitis; and stage IV is characterized by eneralized fecal peritonitis .
An important step in treating colon perforation is to remove the source of infection, as feculent peritonitis leads to a high mortality rate [4,5]. Therefore, emergent exploratory laparotomy with resection of the involved colon is an equally important part of treatment. The patient reported here was transferred to an intensive care unit following surgery and administered intravenous antibiotics to protect against gram-negative and anaerobic pathogens. The pathological report of the surgical specimen identified acute diverticulitis with chronic ulcer, perforation of the cecum, and adenocarcinoma of the cecum.
Colon perforation due to colon diveticulitis and colon cancer is rare. Therefore, surgical resection of the involved colon should extend to tumor free margins. In patients with colon cancer accidentally associated with colon diverticulitis, the surgeon should extend the resection up to hemicolectomy or follow-up with the patient . For the patient reported here, exploratory laparotomy surgery with segmental resection of the cecum and anastomosis of the A-colon and terminal ileum was performed. This allowed us to not only treat the colon condition, but to obtain a surgical specimen upon which a pathological report could be conducted as well.
Figure 1. Perforation in the cecum.
Figure 2. Abdomen CT scan showing the presence of pneumoperitoneum.
5. Constantinides VA, Tekkis PP, Senapati A. Association of Coloproctology of Great Britain Ireland Prospective multicentre evaluation of adverse outcomes following treatment complicated diverticular disease. Br J Surg. 2006, 93(12):1503-1513.