Diagnosis and treatment of spontaneous colonic perforation： Analysis of 10 cases

AIM： To investigate the etiology, diagnosis and treatment of spontaneous perforation of the colon.
METHODS： The clinical data of 10 cases of spontaneous perforation of the colon, observed at Fuding hospital from January 2004 to December 2007, were analyzed retrospectively.
RESULTS： The mean age at onset was 65 years （range from 45 to 73）. Seven patients had a history of chronic constipation. All patients complained of sudden lower abdominal pain. The perforation occurred after coloclysis and administration of senna leaves in two patients. Nine patients had signs of peritoneal irritation. Seven cases underwent abdominal paracentesis, which was diagnostic in six. Only one case was definitely diagnosed prior to surgery. One patient underwent neoplasty of the colon, another a partial resection of colon, six a neoplasty of the colon plus sigmoid colostomy, and two underwent Hartmann surgery. All perforation sites were opposite to the mesenteric edge. The perforation sites were located on descending colon in one case, sigmoid colon in three cases, and rectosigmoid colon in six cases. In five patients, surgical pathological examination was consistent with the microscopical changes of colonic perforation caused by feces. Three patients died after surgery.
CONCLUSION： Spontaneous perforation of the colon most commonly occurs among the elderly with chronic constipation. Abdominal paracentesis is helpful for the diagnosis. The perforation site is located opposite to the mesenteric edge. Sigmoid colon and rectosigmoid colon are the most frequent locations. Neoplasty of the colon and sigmoid colostomy are the most frequent treatment. The prognosis is bad and the mortality rate after surgery is high.     

Subclinical peritonitis due to perforated sigmoid diverticulitis 14 years after heart-lung transplantation

Acute complicated diverticulitis, particularly with colon perforation, is a rare but serious condition in transplant recipients with high morbidity and mortality. Neither acute diverticulitis nor colon perforation has been reported in young heart-lung grafted patients. A case of subclinical peritonitis due to perforated acute sigmoid diverticulitis 14 years after heart-lung transplantation is reported. A 26-year-old woman, who received heart-lung transplantation 14 years ago, presented with vague abdominal pain. Physical examination was normal. Blood tests revealed leukocytosis. Abdominal X-ray showed air-fluid levels while CT demonstrated peritonitis due to perforated sigmoid diverticulitis. Sigmoidectomy and end-colostomy （Hartmann＇s procedure） were performed. Histopathology confirmed perforated acute sigmoid diverticulitis. The patient was discharged on the 8th postoperative day after an uneventful postoperative course. This is the first report of acute diverticulitis resulting in colon perforation in a young heart-lung transplanted patient. Clinical presentation, even in peritonitis, may be atypical due to the masking effects of immunosuppression. A high index of suspicion, urgent aggressive diagnostic investigation of even vague abdominal symptoms, adjustment of immunosuppression, broad-spectrum antibiotics, and immediate surgical treatment are critical. Moreover, strategies to reduce the risk of this complication should be implemented. Pretransplantation colon screening, prophylactic pretransplantation sigmoid resection in patients with diverticulosis, and elective surgical intervention in patients with nonoperatively treated acute diverticulitis after transplantation deserve consideration and further studies.     

Colonoscopic perforation： A report from World Gastroenterology Organization endoscopy training center in Thailand

AIM： To determine the incidence of colonoscopic perforation （CP）, and evaluate clinical findings, management and outcomes of patients with CP from the World Gastroenterology Organization （WGO） Endoscopy Training Center in Thailand. METHODS： All colonoscopies and sigmoidoscopies performed between 1999 and 2007 in the Endoscopic unit, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok were reviewed. Incidence of CP, patients＇ characteristics, endoscopic information, intraoperative findings, management and outcomes were analyzed. RESULTS： A total of 17357 endoscopic procedures of the colon （13 699 colonoscopies and 3658 flexible sigmoidoscopies） were performed in Siriraj hospital over a 9-year period. Fifteen patients （0.09%） had CP： 14 from colonoscopy and 1 from sigmoidoscopy. The most common site of perforation was in the sigmoid colon （80%）, followed by the transverse colon （13%）. Perforations were caused by direct trauma from either the shaft or the tip of the endoscope （n = 12,80%） and endoscopic polypectomy （n = 3, 20%）. All patients with CP underwent surgical management： primary repair （27%） and bowel resection （73%）. The mortality rate was 13% and postoperative complication rate was 53%. CONCLUSION： CP is a rare but serious complication following colonoscopy and sigmoidoscopy, with high rates of morbidity and mortality. Incidence of CP was 0.09%. Surgery is still the mainstay of CP management.     

Clinical significance of granuloma in Crohn＇s disease

AIM: Granuloma is considered the hallmark of microscopic diagnosis in Crohn's disease (CD), but granulomas can be detected in only 21-60% of CD patients. The aim of this study was to evaluate the frequency of granulomas by multiple endoscopic biopsies in patients with CD and to examine whether group of patients with or without granuloma exhibit a different clinical course. METHODS: Fifty-six patients with newly diagnosed CD were included in the study. Jejunoscopy, enteroclysis and ileo-colonoscopy were performed in all patients. At least two biopsy specimens from each examined gastrointestinal segment were examined microscopically searching granuloma. The clinical course was followed in all patients, and extraintestinal manifestations as well as details of any immunosuppressive therapy and surgical intervention were noted. RESULTS: Granuloma was found in 44.6% of the cases (25 patients). Patients with granuloma had higher activity parameters at the time of the biopsies. Extraintestinal manifestations were observed and surgical interventions were performed more often in the granuloma group. The need of immunosuppressive therapy was significantly more frequent in the patients with granuloma. Granuloma formation is mote often seen in younger patients, and mainly in the severe, active penetrating disease. CONCLUSION: The significantly higher frequency of surgical interventions and immunosuppressive therapy suggests that granuloma formation is associated with a more severe disease course during the first years of CD.     

One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding,leaks and fistulas

AIM: To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip(OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas.METHODS: From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients(48.8%) presented with severe upper-gastrointestinal(GI) bleeding, 3(3.6%) patients with lower-GI bleeding, 7 patients(8.3%) underwent perforation closure, 18 patients(21.4%) had prevention of secondary perforation, 12 patients(14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection(ESD) and 3 patients(3.6%) had an intervention on a chronic fistula. RESULTS: In 78/84 patients(92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients(89.28%). The overall mortality in the study patients was 11/84(13.1%) and was seen in patients with life threatning upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41(85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases(57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18(100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen(2%).CONCLUSION: This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.     

Treatment of massive pancreaticojejunal anastomotic hemorrhage after pancreatoduodenectomy

AIM： To compare the treatment modalities for patients with massive pancreaticojejunal anastomotic hemorrhage after pancreatoduodenectomy （PDT）.
METHODS： A retrospective study was undertaken to compare the outcomes of two major treatment modalities： transcatheter arterial embolization （TAE） and open surgical hemostasis. Seventeen patients with acute massive hemorrhage after PDT were recruited in this study. A comparison of two treatment modalities was based upon the clinicopathological characteristics and hospitalization stay, complications, and patient prognosis of the patients after surgery.
RESULTS： Of the 11 patients with massive hemorrhage after PDT treated with TAE, 1 died after discontinuing treatment, the other 10 stopped bleeding completely without recurrence of hemorrhage. AIJ the 10 patients recovered well and were discharged, with a mean hospital stay of 10.45 d after hemostasis. The patients who underwent TAE twice had a re-operation rate of 18.2% and a mortality rate of 0.9%. Among the six patients who received open surgical hemostasis, two underwent another round of open surgical hemostasis. The mortality was 50%, and the recurrence of hemorrhage was 16.67%, with a mean hospital stay of 39.5 d.
CONCLUSION： TAE is a safe and effective treatment modality for patients with acute hemorrhage after PDT. Vasography should be performed to locate the bleeding site.     

Palliative cardia resection with gastroesophageal reconstruction for perforated carcinoma of the gastroesophageal junction

Iatrogenic perforation of esophageal cancer or cancer of the gastroesophageal （GE） junction is a serious complication that, in addition to short term morbidity and mortality, significantly compromises the success of any subsequent oncological therapy. Here, we present an 82-year-old man with iatrogenic perforation of ad- enocarcinoma of the GE junction. Immediate surgical intervention included palliative resection and GE reconstruction. In the case of iatrogenic tumor perforation, the primary goal should be adequate palliative （and not oncological） therapy. The different approaches for iatrogenic perforation, i.e. surgical versus endoscopic therapy are discussed.     

Surgical management of colonic diverticular disease:Discrepancy between right- and left-sided diseases

AIM:To compare the outcome of the surgical management of left-sided and right-sided diverticular disease.METHODS:The medical records of 77 patients who were surgically treated for diverticular disease between 1999 and 2010 in a tertiary referral hospital were retrospectively reviewed.The study population was limited to cases wherein the surgical specimen was confirmed as diverticulosis by pathology.Rightsided diverticula were classified as those arising from the cecum,ascending colon,and transverse colon,and those from the descending colon,sigmoid colon,and rectum were classified as left-sided diverticulosis.To assess the changing trend of occurrence of diverticulosis,data were compared with two previous studies of 51 patients.RESULTS:The proportion of left-sided disease cases was significantly increased compared to the results of our previous studies in 1994 and 2001,(27.5%vs48.1%,P<0.05).Moreover,no differences in gender,body mass index,multiplicity of the diverticula,fever,or leukocytosis were noted between patients with rightsided and left-sided disease.However,patients with right-sided disease were significantly younger(50.9year vs 64.0 year,P<0.01).Furthermore,left-sided disease was significantly associated with a higher incidence of complicated diverticulitis(89.2%vs 57.5%,P<0.01),combined resection due to extensive inflammation(21.6%vs 5.0%,P<0.05),operative complications(51.4%vs 27.5%,P<0.05),and in-hospital mortality(10.8%vs 0%,P<0.05),along with longer post-operative hospitalization duration(21.3±10.2 d vs 10.6±8.1 d,P<0.05).CONCLUSION:Compared with right-sided diverticular disease,the incidence of left-sided disease in Korea has increased since 2001 and is associated with worse surgical outcomes.     

Iatrogenic colorectal perforation induced by anorectal manometry： Report of two cases after restorative proctectomy for distal rectal cancer

There are no reports regarding perforation of the colorectum induced by anorectal manometry. We report two cases of colorectal perforation that occurred during manometry in the patients undergoing restorative proctectomy for distal rectal cancer. In the first patient, computed tomography showed an extraperitoneal perforation in the pelvic cavity and a rupture of the rectal wall. A localized perforation into the retroperitoneum was managed conservatively. In the second patient, a 3 cm linear colon rupture was detected above the anastomotic site. A primary closure of the perforated colon and proximal ileostomy were conducted, but the patient died 2 wk later. We hypothesize that the perforation induced by anorectal manometry may be associated with the relative weakening of the proximal bowel wall due to anastomosis, decreased compliance, and abnormal rectal sensation. We suggest that measurement of the maximum tolerable volume should not be routinely performed alter restorative proctectomy for distal rectal cancer.     

Virtual colonoscopy-induced perforation in a patient with Crohn＇s disease

We report a case of sigmoid colon perforation in a patient with Crohn's disease undergoing computed-tomographic (CT) colonography. A 70-year-old patient with Crohn's disease with terminal ileitis and sigmoid stricture underwent CT colonography after incomplete conventional colonoscopy. During the procedure, the colon was inflated by air insufflation and the patient developed abdominal pain with radiological evidence of retroperitoneal and intraperitoneal free gas. Hartmann's operation was performed. This case highlights that CT colonography is not risk-free. The risk of perforation may be higher in patients with inflammatory bowel disease.     

Use of accurate diagnostic criteria may increase incidence of stercoral perforation of the colon

PURPOSE: Stercoral perforation of the colon is reported to be a rare disease with poor prognosis. The aim of this study was to determine the frequency of stercoral perforation of the colon, to define diagnostic criteria for stercoral perforation of the colon, and to analyze the patient outcome in a university hospital gastrointestinal surgery unit. METHODS: From November 1993 until November 1998 all surgically treated patients with a colorectal disease were prospectively recorded in a computerized database. Diagnosis of stercoral perforation of the colon was made if 1) the colonic perforation was round or ovoid, exceeded 1 cm in diameter, and lay antimesenteric; 2) fecalomas were present within the colon, protruding through the perforation site or lying within the abdominal cavity; and 3) pressure necrosis or ulcer and chronic inflammatory reaction around the perforation site were present microscopically. Any additional colon pathology led to exclusion from the diagnosis of stercoral perforation of the colon. Using the same criteria, 81 cases in the literature were found to qualify and were further analyzed. RESULTS: In a five-year period 1,295 patients underwent colorectal interventions through laparotomy. A total of 566 (44 percent) cases were emergencies, 220 (17 percent) of these caused by colonic perforation. Seven patients had stercoral perforation of the colon. The incidence of stercoral perforation of the colon was 0.5 percent of all surgical colorectal procedures through laparotomy, 1.2 percent of all emergency colorectal procedures, and 3.2 percent of all colonic perforations. The mean age of the patients was 59 (median, 64; range, 22–85) years. All perforations were situated in the left hemicolon or upper rectum. The round or ovoid perforation had a mean diameter of 3.6 cm. Fecalomas were present in all patients and protruded from the perforation site or were found within the free abdominal cavity in three of them. Generalized stercoral peritonitis was a constant finding. Using a colonic resection without immediate restoration of continuity, an extensive intraoperative lavage, and antibiotics, there was no in-hospital mortality. Analysis of the reports in the literature revealed additionally that 28 percent of patients with stercoral perforation of the colon have multiple stercoral ulcers in the colon and that substantial mortality is encountered if only minor surgical procedures of treatment are used. CONCLUSIONS: The incidence of stercoral perforation of the colon seemed to have been underestimated. The reason for this might be the lack of defined diagnostic criteria for this disease. Low mortality is obtained by early surgical eradication of the affected part of the colon, including all stercoral ulcers, and by aggressive therapy for peritonitis.Presented in part at the meeting of the Swiss Society of Surgery, Lugano, Switzerland, June 9 to 12, 1999.     

老年人粪性结肠梗阻与穿孔诊治的体会

目的 分析老年人粪性结肠梗阻与穿孔的临床特征，以提高诊治水平。方法 对1994年1月至2003年12月收治的22例老年粪性结肠梗阻与6例粪性结肠穿孔患者资料进行回顾性分析。结果 粪性结肠梗阻22例，6例分别以肠梗阻、结肠占位病变行手术治疗，16例行保守治疗，均痊愈。粪性结肠穿孔6例，分别以结肠恶性肿瘤穿孔、肠绞窄行手术治疗，穿孔部位多见于直-乙状结肠交界处，2例因感染性休克、多器官功能衰竭死亡。结论 粪性结肠梗阻患者经保守治疗多能缓解症状。粪性结肠穿孔比较罕见，缺乏特异性临床表现，误诊率和病死率高，应积极行手术治疗，切除病变肠段、行Hartmann造瘘术为首选。     

Stercoral perforation proximal to the stapled anastomosis after low anterior resection with an intraluminal device

Stercoral perforation of the colon is a rare phenomenon and a potential life-threatening condition requiring acute intervention. A little more than 200 cases have been described to date. The mechanism is not completely understood. In this short communication, we present three patients with a colon perforation proximal to the anastomosis, similar to a stercoral perforation, following colorectal cancer resection with application of an intraluminal device, the C-seal.     

Giant Fecaloma With Idiopathic Sigmoid Megacolon

PURPOSE: Fecal impaction is a common condition, and " fecaloma" is an extreme variety of impaction. This is a report of a giant, solitary, and stubborn fecaloma not responding to nonoperative management. A surgical intervention for uncomplicated fecal impaction is rarely needed and reported in the literature. METHOD: A 39-year-old male patient with constipation presented with a firm, mobile, abdominal mass of six-months duration. Investigations revealed an isolated, giant fecaloma in a redundant sigmoid megacolon. After all the conservative measures were unsuccessful in evacuating the stubborn impaction, he was treated by sigmoid colectomy and primary anastomosis. CONCLUSION: A timely surgical intervention in recalcitrant fecal impactions may prevent possible stercoral ulcer perforation with a high mortality.     

Stercoral ulceration and perforation of the sclerodermatous colon: Report of two cases and review of the literature

Summary The pathologic changes which attend sclerodermatous involvement of the colon suggest that stercoral ulceration associated with spontaneous perforation may be a common accompaniment. However, this is a triad rarely encountered. The authors describe two such cases and discuss the diagnosis, pathologic anatomy and management of patients with stercoral ulceration and bowel perforation, particularly when associated with scleroderma.     

Sigmoid perforation in patients with chronic constipation

From 1976 to 1982, seven cases of free perforation of the sigmoid colon were treated at the Soroka University Hospital. None of the patients suffered any known underlying disease of the affected bowel such as malignancy, diverticulosis, stercoral ulcer, colitis, or trauma. The only feature common to all seven patients was a long history of chronic constipation. All patients were treated surgically with no mortality and with minimal morbidity. We believe that severe untreated chronic constipation may, on rare occasions, cause free perforation of the sigmoid colon.     

Stercoral perforation of the colon in a heroin addict

BACKGROUND AND AIMS: Stercoral perforation of the colon is rare. Narcotics are well known to produce chronic constipation resulting in stercoral perforation, however, only one case of a heroin addict developing stercoral perforation has been reported. PATIENTS AND METHODS: We present a case of a 67 year-old man with chronic heroin use and stercoral perforation requiring sigmoidectomy and Hartmann's procedure. Computed tomography was performed prior to exploration. RESULTS: This is the first case of computed tomography findings, prior to laparotomy, that have been published for stercoral perforation.     

Perforation isolée du sigmoïde par ingestion de prothèse dentaire : à propos de deux cas

The authors relate two cases of acute stercoral peritonitis secondary to the perforation of sigmoid colon, by accidental ingestion of a dental prosthesis. Clinically, the patients presented symptoms of acute peritonitis. The antecedents of chronic smoking and repeated epigastric pain suggested the diagnosis of ulcer perforation in one patient. At laparotomy, we found a perforation of sigmoid colon, with a dental prosthesis wedged in the perforation in the two patients. The perforation was exteriorized on a stick, and the reestablishment of continuity made three months later. The prosthesis has been accidentally ingested during sleep.     

Diagnosis and treatment strategies of tuberculous intestinal perforations: a case series

Gastrointestinal tuberculosis (TB) may result in intestinal obstruction and perforation, even after antituberculous therapy has been initiated. Despite surgical intervention tuberculous perforation has a high complication and mortality rate, and it is difficult to predict the subgroup of patients with abdominal TB who progress to perforation. In this study, we retrospectively investigated the clinical features that may predict disease progression in patients in our institution who presented abdominal TB over a 5-year period between January 2006 and August 2011, as well as describe an unreported method of managing tuberculous intestinal perforations when resection with end-to-end anastomosis is unfeasible. Six out of 91 patients (6.6%) with abdominal TB developed perforations. Factors linked with increased complications and mortality were age, comorbidities, multiple perforations and length of time between onset of abdominal symptoms and perforation. Four patients (66.7%) had long histories of abdominal symptoms before perforation. Three patients were receiving or had completed antituberculous therapy before developing perforation. Five patients were managed surgically, two underwent laparostomy as both primary closure and end-to-end anastomosis were deemed too risky. Mortality following perforation was 17%. Patients with prolonged abdominal symptoms, even after antituberculous therapy, should raise suspicion for subacute intestinal obstruction. This should be recognized early and surgical intervention considered in order to prevent mortality secondary to perforation. Laparostomy may be an alternative when resection and end-to-end anastomosis is not possible.