An Unusual Incidental Finding in a Patient With Colon Perforation

Abstract

Question: A 74-year old man presented to our emergency department with acute abdominal pain and rectal bleeding. One week before admission, he underwent endoscopic laser therapy because of colonic angiodysplasia and polyposis. On clinical examination, his abdomen was painful in the right paraumbiblical region. CT was performed (Figure, transverse [A], coronal [B, C], and sagittal [D] reconstruction). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CT revealed free intraabdominal air and fluid (Figure E-H). Additionally, thickening of the cecal wall is also seen. Furthermore, a long metallic line extending from the heart via the diaphragm into the stomach and duodenum was detected (Figure E-H, arrows). A further metallic line was identified in the pelvis. Intraoperatively, a large perforation of the cecum owing to local ulcerations as complication of the previous laser therapy was diagnosed and a right hemicolectomy was performed. Furthermore, both metallic lines were also removed. The line was sheared below the diaphragm. The intragastral/intraduodenal part of the line was extracted without difficulty. No surgical suture was necessary to close the small gastric perforation. Additional investigation of the lines revealed 2 temporary epicardial pacing wires (Figure I). The postoperative course was uneventful and the patient was discharged from the hospital 3 weeks later. A requestioning of the patient revealed a history of aortic valve implantation and coronary artery bypass grafting with placement of temporary epicardial pacing wires, 9 years before the admission. Temporary epicardial pacing wires (TEPW) are used routinely in open heart operations for therapeutic as well as diagnostic purposes.1Lazarescu C. Kara-Mostefa S. Parlanti J.M. et al.Reassessment of the natural evolution and complications of temporary epicardial wires after cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 506-511Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar TEPW tips are placed intramuscular in the anterior wall of the right ventricle, and the distal ends are localized epicutaneously.1Lazarescu C. Kara-Mostefa S. Parlanti J.M. et al.Reassessment of the natural evolution and complications of temporary epicardial wires after cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 506-511Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Although the use of TEPW is safe and simple, placement of removal of TEPW can be associated with rare but serious complications, such as heart failure, cutaneous abscesses, or fistula formation.1Lazarescu C. Kara-Mostefa S. Parlanti J.M. et al.Reassessment of the natural evolution and complications of temporary epicardial wires after cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 506-511Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Some reports have described complications caused by dislocation of TEPW.1Lazarescu C. Kara-Mostefa S. Parlanti J.M. et al.Reassessment of the natural evolution and complications of temporary epicardial wires after cardiac surgery.J Cardiothorac Vasc Anesth. 2014; 28: 506-511Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 2Guerrieri Wolf L. Scaffa R. Maselli D. et al.Intraaortic migration of an epicardial pacing wire: percutaneous extraction.Ann Thorac Surg. 2013; 96: e7-e8Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar For example, Guerrieri Wolf et al2Guerrieri Wolf L. Scaffa R. Maselli D. et al.Intraaortic migration of an epicardial pacing wire: percutaneous extraction.Ann Thorac Surg. 2013; 96: e7-e8Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar reported a case of intraaortic migration of TEPW. Colonic perforation during placement of TEPW has been also reported previously.3Salami M.A. Coleman R.J. Buchan K.G. Colonic injury from temporary epicardial pacing wires.Ann Thorac Surg. 2012; 93: 1309-1311Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In our case, clinically silent diaphragm and stomach perforation by TEPW occurred. To our best of knowledge, this constellation has not been reported previously.