A Complicated Case of Perforated Diverticulitis with Septic Embolization

Abstract

Introduction: Acute diverticulitis occurs when fecal matter obstructs the orifice of a diverticulum and local infection ensues. Inflammation can result in reduced tissue perfusion leading to focal necrosis and perforation. A small perforation may be walled off by omentum and present as a localized abscess. Disruption of tissue and vascular integrity may result in the siphoning of gas into the vascular system. Rarely intravascular gas leads to thrombosis and septic emboli. Case Report: We are reporting an interesting case of a 54-year-old male with history of alcohol abuse presented with one week of fever, chills, diffuse, crampy abdominal pain and diarrhea. He was febrile with leukocytosis, elevated LFT's and hyperbilirubinemia. CT of the abdomen revealed mesenteric gas with likely source arising from sigmoid colon and small areas of hypoenhancement within the spleen possibly areas of infarct. Antibiotics were administered. Patient's condition continued to deteriorate with high temperatures, diarrhea and increasing leukocytosis. On seventh day of hospitalization, CT scan revealed gas in the mesenteric vein extending into the portal vein and its branches. The mesenteric venous gas was traced back and appeared to originate from the sigmoid colon. The liver and spleen revealed areas of infarction. Clinically he appeared to have perforated diverticulitis with the ominous sign of venous gas and septic emboli. He was transferred to a referral hospital where he had exploratory laparotomy with anterior resection of the sigmoid colon and a prolonged postoperative antibiotic course. On follow-up, he was healthy and had no gastrointestinal complaints. Discussion: This patient presented with classic findings of acute diverticulitis and CT of the abdomen revealed mesenteric vein air contiguous with sigmoid colon extending to the portal vein and its branches and infarcts in the liver and spleen. Hepatic portal venous gas is a rare entity and along with septic emboli is an ominous sign suggestive of severe mortality. It is usually noted in bowel ischemia and in rare cases it can also be seen with complicated colonic diverticulitis. Conclusion: In conclusion, it is important to be aware of septic emboli and venous thrombosis as a complication of diverticulitis with perforation. The findings of venous gas, septic emboli or venous thrombosis necessitate urgent surgery intervention. Since diverticulitis is such a common entity, complications should be anticipated and physicians should be aware of rare complications such as septic emboli leading to liver and splenic infarcts. Air in the hepatic portal venous system is always an ominous sign and requires immediate surgical intervention.Table: No Caption available.