Spontaneous Colonic Perforation Research Articles

C4 (Clinical Case) Vascular Ehlers-Danlos Syndrome in the Paediatric Population: A Case Report of an Internal Bleed Caused by Ruptured Pseudoaneurysm

Abstract Introduction/Background Ehlers-Danols syndrome (EDS) is a connective tissue disease characterized by joint hypermobility, skin hyperextensibility and tissue fragility. EDS has six types. Type IV EDS: vascular EDS (vEDS), is rare but also the most malignant. Case Description We report a 15-year-old boy with a previous history of spontaneous colon perforation and two left shoulder dislocations. He presented with sudden onset abdominal pain, vomiting, dizziness, and lethargy with a Glasgow coma scale of 13. His abdomen was soft but mildly tender. He had a capillary refill of 3 seconds with cold extremities, was found to be in a hypotensive shock state requiring resuscitation with fluids and inotropes, as well as intubation and mechanical ventilation. His hemoglobin dropped by 30 g/L in 6 hours. Therefore, an abdominal ultrasound was done, revealing an intrabdominal hematoma. CT scan of the abdomen confirmed a ruptured fusiform pseudoaneurysm of the accessory left hepatic artery. This was successfully managed by coil embolization, see F1 and F2, below. Genetic workup was positive for the pathogenic COL3A1 gene that presents phenotypically as Ehlers-Danlos syndrome, particularly type IV. Discussion COL3A1 encodes pro-alpha1 chains of type III collagen. Inheritance is autosomal-dominant. It can present as a de novo variant with a negative family history, as was the situation for our patient. Estimated affected people with de novo variant vEDS is 33%-50%. Clinical diagnosis of vEDS involves one major and several minor criteria (2017). Major criteria include arterial aneurysms, dissection, or rupture; intestinal rupture; uterine rupture during pregnancy; family history of vEDS. Minor criteria include easy bruising; thin skin and visible veins; facial characteristics including prominent eyes, narrow nasal bridge, thin lips; club foot, congenital hip dislocation; inguinal hernia and pneumothorax. Our patient had two elements from the major criteria: arterial pseudoaneurysm and intestinal rupture. Conclusion vEDS has high morbidity and mortality due to the risk of spontaneous internal organ/vessel injury. This can be mitigated by increased awareness of systemic manifestations of vEDS and a high index of suspicion by both primary care and emergency physicians. Once diagnosed, surveillance is crucial, including regular blood pressure monitoring, frequent non-invasive imaging to identify emerging vascular lesions, and pregnancy counselling for potential uterine rupture and avoiding trauma, collision sports, and lifting heavy items.

A case of colonic perforation in collagenous colitis without diarrheal symptoms.: A case report

Collagenous colitis is an inflammatory disease characterized by hyperplasia of the collagen band beneath the colonic mucous membrane. Chronic diarrhea is a characteristic clinical symptom. The disease is often diagnosed accidentally on colonoscopy for chronic diarrhea, and patients without chronic diarrhea have few chances to suspect the disease.The patient was a 75-year-old woman. The chief complaint was sudden upper abdominal pain and vomiting. There were no important findings regarding the consumed food or bowel habits (no diarrhea). Computed tomography revealed wall thickness and a small amount of free air around the descending colon. An emergency laparotomy was performed with the diagnosis of spontaneous colonic perforation. Intra-operative findings revealed a longitudinal ulcer and micro-perforation to the mesenterial side at the descending colon. Pathological findings revealed subepithelial collagenous band in the submucosal background of the ulcer, and which was diagnosed as collagenous colitis.Intestinal perforation in collagenous colitis is extremely rare. It was considered that perforation was caused by a transient increase in intestinal pressure in the background of collagenous colitis. Further, to the best of our knowledge, this is the first report of a critical case which presented without the characteristic symptom of chronic diarrhea.We report a rare case of colonic perforation of the collagenous colitis.

Acute Spontaneous Colonic Perforation in a Case of Newly Confirmed Scleroderma: Case Report.

Scleroderma is a group of autoimmune diseases that principally affects the skin, blood vessels, muscles, and viscera. One of the more well-known subgroups of scleroderma is the limited cutaneous form of the multisystem connective tissue disorder known as CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasis) syndrome. In this report, we present a case of a spontaneous colonic bowel perforation in a patient with incomplete features of CREST. Our patient underwent a complicated hospital course involving broad-spectrum antibiotic coverage, surgical hemicolectomy, and immunosuppressives. She was eventually discharged home with a return to functional baseline status after esophageal dysmotility confirmation via manometry. Physicians managing patients with scleroderma ensuing to an emergency department encounter must anticipate the multitude of complications that can occur, as was seen in our patient. The threshold for pursuing imaging and additional tests, in addition to admission, should be relatively low, given the extremely high rates of complications and mortality. Early multidisciplinary involvement with infectious disease, rheumatology, surgery, and other respective specialties is crucial for patient outcome optimization.

S2136 Spontaneous Colonic Perforation as an Unusual Presentation of COVID-19 Infection: Case Report and Review of Literature

S2136 Spontaneous Colonic Perforation as an Unusual Presentation of COVID-19 Infection: Case Report and Review of Literature

Laparoscopic Management of Spontaneous Colonic Perforation: A Single Institution Study of 52 Patients.

Spontaneous colonic perforation (SCP) is associated with an devastating result. The use of laparoscopy for SCP remains controversial. This study aimed to compare the postoperative outcomes of patients who received either laparoscopic or open surgery and to evaluate the efficacy of laparoscopic surgery and the risk factors affecting prognosis. A retrospective study of patients who underwent surgery for SCP from January 2005 to December 2020 was performed. Demographic data, intraoperative variables, length of stay, and surgical complications were retrieved. A total of 52 patients were postoperatively diagnosed with SCP. Thirty (57.69%) procedures were performed using laparoscopic surgery (group A) and 22 (42.31%) were performed using open surgery (group B). There were no significant differences between groups A and B in terms of age, sex, chronic concomitant disease, chronic constipation, incentives, imaging findings, preoperative diagnosis, American Society of Anesthesiologists (ASA) score, Mannheim Peritonitis Index (MPI), operation time, days to resumption of liquids, site of perforation, surgical procedures, or types of perforation ( P >0.05). The incidence of wound infection in group A was significantly lower than that in group B ( P <0.05), but there was no significant difference in the incidence of abdominal abscess between the 2 groups ( P >0.05). Significant differences were found in days to start walking and days to resumption of solids between the 2 groups ( P <0.05). Group B had a longer length of hospital stay than group A ( P <0.05). After multivariate analysis, the independent variables associated with worse perioperative complications were an age of 65 years and older, an ASA score of ≥3, and an MPI of >26. The prognosis of SCP is poor. The operation should follow principles that are simple, rapid, and effective. If there are no contraindications, laparoscopy may be the preferred method. Hartmann procedure is a promising surgical strategy. The age, ASA score, and MPI may indicate the severity and prognosis of SCP.

Idiopathic Myointimal Hyperplasia of Mesenteric Veins (IMHMV) with two spontaneous bowel perforations: A case report and literature review.

Introduction and importanceIdiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a poorly understood disorder which poses a diagnostic challenge to clinicians and pathologists. Here we have described the case of a male patient with IMHMV along with a presumed history of ulcerative colitis for 1 year.Case presentationA 55-year-old male presented to the OPD with history of chronic abdominal pain. Clinical and radiological examination coupled with endoscopic findings resulted in the patient being wrongly diagnosed to be a case of ulcerative colitis and was managed accordingly. Throughout his multiple hospital visits following treatment for ulcerative colitis, the patient was persistently symptomatic. He presented with 10 days history of increasing abdominal pain and constipation following which he developed spontaneous colonic perforation for which he underwent exploratory laparotomy left colectomy and Hartman's procedure. The final pathology of the resected colon found to be consistent of Idiopathic myointimal hyperplasia of the mesenteric veins and ischemic bowel changes.Clinical discussionThe absence of clear-cut endoscopic biopsy findings of ulcerative colitis made radiological picture to be the mainstay for diagnosis, which was inaccurate and exposed the patient to unnecessary treatment with immuno-modulators thus resulting in poor response to treatment. As the disease progressed, further narrowing of the vessels made the clinical picture to look closer to ischemic bowel pathology as the patient developed a top surgical emergency (i.e. bowel perforation). Such pathological finding (IMHMV) can only be diagnosed in a fully prepared tissue histology, but rather be considered when no other consistent alternative diagnosis was found.ConclusionThe treating physicians must definitely consider the possibility of idiopathic myointimal hyperplasia of mesenteric veins when similar manifestations are encountered in biopsy specimens of old cases with suspected inflammatory bowel disease or non-occlusive ischemia of the distal colorectum.

Is a Total Colectomy a Better Surgical Treatment for Spontaneous Colonic Perforation that Developed during Bevacizumab Treatment for Extra-intestinal Cancers?

Is a Total Colectomy a Better Surgical Treatment for Spontaneous Colonic Perforation that Developed during Bevacizumab Treatment for Extra-intestinal Cancers?

Ehlers\u2013Danlos syndrome type IV: a case report of a rare cause of spontaneous sigmoid perforation and enteroatmospheric fistulae in a child

BackgroundEhlers–Danlos syndrome (EDS) type IV is a rare subtype of EDS, but has important surgical implications.Case presentationHere, we present a case of a spontaneous sigmoid perforation in a 14-year-old boy. He was initially treated with laparotomy, oversew of the sigmoid perforation and a diverting ileostomy. He developed a complete wound dehiscence and enteroatmospheric fistulae. These were managed with a combination of negative pressure wound therapy and Eakin (TG Eakin™) pouch changes. We discuss the clinical features and presentation of EDS type IV, the surgical implications of managing patients with the condition, and the challenges in management of enteroatmospheric fistulae in children.ConclusionsEhlers–Danlos syndrome type IV should be considered as a cause of any spontaneous colonic perforation in children.

Drain site enterocutaneous fistula after hyperthermic intraperitoneal chemotherapy

Spontaneous sigmoid colon perforation after cytoreduction surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is a rare complication. It is more commonly seen with mitomycin‐based HIPEC. This case study's patient presented with pus discharge at the drain site after 4 weeks of surgery. The symptoms persisted after conservative treatment. High suspicion after the feculent smell of the discharge fluidled to the prompt diagnosis of enterocutaneous fistula. There was limitedperforation with abscess formation, followed by fistula formation. The patient was treated successfully with surgery.

Occult Colonic Perforation in a Patient With Coronavirus Disease 2019 After Interleukin-6 Receptor Antagonist Therapy.

BackgroundInterleukin-6 blockade (IL-6) has become a focus of therapeutic investigation for the coronavirus disease 2019 (COVID-19).MethodsWe report a case of a 34-year-old with COVID-19 pneumonia receiving an IL-6 receptor antagonist (IL-6Ra) who developed spontaneous colonic perforation. This perforation occurred despite a benign abdominal exam and in the absence of other known risk factors associated with colonic perforation.ResultsExamination of the colon by electron microscopy revealed numerous intact severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virions abutting the microvilli of the colonic mucosa. Multiplex immunofluorescent staining revealed the presence of the SARS-CoV-2 spike protein on the brush borders of colonic enterocytes that expressed angiotensin-converting enzyme 2. However, no viral particles were observed within the enterocytes to suggest direct viral injury as the cause of colonic perforation.ConclusionsThese data and absence of known risk factors for spontaneous colonic perforation implicate IL-6Ra therapy as the potential mediator of colonic injury in this case. Furthermore, this report provides the first in situ visual evidence of the virus in the colon of a patient presenting with colonic perforation adding to growing evidence that intact infectious virus can be present in the stool.

Spontaneous colonic perforation in adults: Evaluation of a pooled case series.

Spontaneous colonic perforation in adults (SCPA) is rare but important. Its clinicopathological features and outcomes remain unclear. Therefore, the aim of the current study was to explore and investigate the clinicopathological characteristics, clinical outcomes and potential risk factors for patients with SCPA. Data of seven patients with SCPA treated in our hospitals from January 2008 to December 2017, and 221 cases from research databases before 2018 were retrospectively analyzed. The description of SCPA included stercoral perforation of the colon (SPC), idiopathic perforation of the colon (IPC) and spontaneous colonic perforation (SCP) in the study. All SCPA patients presented with unexplained abdominal pain and peritonitis. The median age was 62.5 years. The definite diagnosis preoperatively was 20.6%. The commonest lesion location was sigmoid colon and Hartmann's operation accounted for 59.3%. Histopathology of stercoral perforation (HSP) and histopathology of idiopathic perforation (HIP) were two histopathological findings. Postoperative complication was 67.7% and mortality was 31.1%. Univariate and multivariate analyses showed that chronic constipation was an independent risk factor for histopathological features (p ≤ 0.001, p = 0.005). Age of patients was associated with both postoperative complication (p = 0.012, p = 0.044) and mortality (p = 0.013, p = 0.034). Univariate analysis showed that HSP was associated with postoperative complication (p = 0.015). Our findings from the analysis pertaining to SCPA confirm those from previous studies, supporting the SCPA, as a uniform description, is an infrequent and life-threatening disease requiring early surgical intervention. We found that the elderly with chronic constipation was a high-risk category and those with HIP had a more favorable outcome than that of patients with HSP.

Multiple idiopathic cecal perforation in a term neonate

Neonatal spontaneous colonic perforation in term neonates is a rare phenomenon, cecal perforation being seldom reported. We report a case of spontaneous cecal perforation in a term, large for gestational age neonate, who became symptomatic on day 2 of life with vomiting and abdominal distension. On exploration, three large full-thickness cecal perforations with necrotic cecum were noted. Histopathologic samples were negative for necrotizing enterocolitis and Hirschsprung's disease. Clinical awareness of this rare entity could help in preventing delay in imaging and prompt surgical management.

1556 IBD Mimicker: Vascular Ehlers-Danlos Presenting as Spontaneous Bowel Perforation

INTRODUCTION: Many diseases can mimic the clinical presentation of inflammatory bowel disease (IBD). Careful history to establish an event timeline that includes symptom onset and evolution, physical exam, imaging, pathology, and endoscopy can help narrow the differential. Here, we present a case of spontaneous colonic perforation due to vascular Ehlers Danlos Syndrome (vEDS) that was initially treated as IBD. CASE DESCRIPTION/METHODS: A 35 year old male with past medical history of childhood retinoblastoma s/p resection and chronic constipation (unremarkable colonoscopy 3 years prior) presented to clinic for a second opinion on a recent diagnosis of IBD. He had been in his usual state of health until 6 months prior to consultation, when he developed abdominal distension, followed by diffuse abdominal pain and vomiting. CT identified a bowel transition point in the mid-abdomen with pneumoperitoneum, prompting emergent exploratory laparotomy, during which sigmoid colon perforation was identified. Notably, no diverticular disease was present near the perforation site and the operative report commented on significant friability and tearing of the mesentery and small bowel. He ultimately underwent sigmoidectomy, ileocecetomy, and colonic mucous fistula creation. A commercially available IBD panel test returned positive and the patient was treated as presumptive Crohn Disease with infliximab, as well as frequent prednisone tapers. Upon referral to our center, the surgical pathology was reviewed and acute findings consistent with perforation were noted; no chronic inflammatory changes were found on either colonic or small bowel samples. CT enterography was unremarkable with respect to the bowel; however, the study incidentally identified dissection of the right common iliac down to the proximal superficial femoral artery. The patient was referred to Clinical Genetics, with subsequent testing revealing a COL3A1 mutation, diagnostic for vEDS. DISCUSSION: A broad differential beyond IBD should be maintained in cases of spontaneous bowel perforation. Unexpected tissue fragility should raise the possibility of a connective tissue disorder, and genetic testing is indicated if the perforation originates from the sigmoid in particular, as this is one of the major vEDS diagnostic criteria. In gastroenterology practice, unnecessary endoscopic procedures should be avoided whenever possible, and in cases where surgery is required, experienced colorectal surgeons should be consulted.

Management of colonic complications of type IV Ehlers-Danlos syndrome: a systematic review and evidence-based management strategy.

Type IV Ehlers Danlos Syndrome (EDS) is a connective tissue disorder affecting approximately 1 per 100,000-200,000 people. Life expectancy is reduced secondary to spontaneous vascular rupture or colonic perforation. Surgery carries significant morbidity and mortality. While strategies to manage colonic perforation include primary repair with or without a defunctioning stoma, Hartmann's procedure, total abdominal colectomy with end ileostomy and ileorectal anastomosis, evidence is contradictory and has not previously been evaluated in order to form a treatment strategy. We aim to review the published literature and identify outcome data relating to operative management of colonic perforation in type IV EDS. Pubmed, EM-BASE, Cochrane library and Google Scholar were searched with the following details: Ehlers Danlos Syndrome AND colonic surgery. The main outcome measure was re-perforation rates following colonic surgery on patients with type IV EDS. If the nature of surgery and follow up were reported, data were recorded in a SPSS database according to PRISMA guidelines. One hundred and nine operations have been described in 51 patients in 44 case series. There were 26 visceral re-perforations, 2 affecting the small intestine and 24 colonic. Survival analysis favoured total abdominal colectomy compared with operations where the colon was left in situ. Total abdominal colectomy with end ileostomy or ileorectal anastomosis are the safest strategies after colonic perforation in type IV EDS. Anastomotic leak rates are high. End colostomy is high risk for colonic re-perforation and anastomotic leak rates are extremely high. Restoration of colonic continuity should be avoided.

A case of spontaneous colonic perforation in collagenous colitis

BackgroundCollagenous colitis (CC) is a clinicopathologic syndrome characterized by chronic watery diarrhea and distinctive histopathologic features. Spontaneous perforation of CC is extremely rare, because CC is usually managed medically, and the need for surgical intervention is rare. We report a surgical case of spontaneous colonic perforation of CC with acute abdomen disease.Case presentationA 77-year-old man was admitted to our hospital for abdominal pain and watery diarrhea. Computed tomography (CT) showed a thickened bowel wall with edema involving free air around the splenic flexure of the colon. Therefore, we performed emergency surgery with a diagnosis of colonic perforation. Intraoperative findings revealed colonic necrosis at the splenic flexure, so we performed a left hemicolectomy. Histopathological examination revealed typical findings of CC, a thick subepithelial collagenous band and deep ulcers with perforation. The postoperative course was uneventful, and the patient was discharged on the 28th postoperative day. After changing the proton pump inhibitor (PPI) from lansoprazole (LPZ) to rabeprazole (RPZ), he has not complained of diarrhea symptoms.ConclusionsAlthough spontaneous perforation is a rare complication of CC, it is possible to be diagnosed by symptom of acute abdomen disease. This is the seventh case of spontaneous colonic perforation of CC worldwide.

Laparoscopic diverting loop ileostomy for spontaneous colon perforation in advanced ovarian cancer

ObjectiveNeoadjuvant chemotherapy for advanced ovarian cancer is associated with reduced morbidity in the elderly (Meyer et al., 2018). Spontaneous colonic perforation often leads to multisystem organ failure and death (Carter and Durfee, 2007; Rose and Piver, 1995). MethodsA 76-year old woman with stage IIIC disease initiated carboplatin AUC 5 and paclitaxel 175 mg/m2 with unanticipated development of profound neutropenia. She clinically deteriorated by day nine and CT scan revealed a large volume of free air. Emergent surgery was performed. ResultsDiagnostic laparoscopy confirmed the presence of intra-abdominal stool and extensive inflammatory exudate (Video). The likelihood of identifying the site of perforation appeared remote, but pelvic tumor encasement was highly suggestive of a sigmoid origin. The stool was evacuated, the exudate gently debrided and the terminal ileum partially mobilized. Copious irrigation was performed with drain placement and the pneumoperitoneum was decompressed. The right lower abdominal wall trocar incision was extended so that the ileal segment could be brought out and matured. She was discharged to rehab on postoperative day 2 to continue a two week course of broad spectrum antibiotics. Single-agent carboplatin was resumed within a month. Uncomplicated ileostomy takedown with parastomal hernia repair was performed between cycles five and six. The patient is currently in remission. ConclusionBowel perforation in the elderly, presenting with cachexia and treatment-induced pancytopenia for advanced ovarian cancer, is often a harbinger of early death. Selected patients may benefit from a minimally invasive approach by an experienced gynecologic oncologist instead of vertical laparotomy, abdominal washout, diversion and the potential sequelae of an open abdomen.

Clinical characteristics of colitis induced by taxane-based chemotherapy.

Background:Limited data are available concerning the clinical features of toxic gastrointestinal (GI) effects of taxane-based therapy. We describe the clinical, endoscopic and histologic features of taxane-induced colitis.Methods:This retrospective study included cancer patients who received taxane therapy and underwent colonoscopy for GI symptoms from 2000-2018.Results:Of the 45,527 patients who received taxane therapy during the study period, 76 (0.2%) met the inclusion criteria. Most patients (54%) received paclitaxel, 37% docetaxel, and 9% nab-paclitaxel. The median time from taxane therapy initiation to colitis symptom onset was 31 days. The median duration of colitis symptoms was 30 days. Colitis treatment comprised immunosuppressive therapy in 8 patients (11%), antibiotics in 17 (22%), antimotility agents in 18 (24%), and octreotide or somatostatin in 2 (3%). Thirty-five patients (46%) required hospitalization and seven (9%) required admission to the intensive care unit (ICU). Endoscopy revealed mucosal ulceration in 19 patients (25%), nonulcerative inflammation in 32 (42%), and normal findings in 25 (33%). Seventeen patients (22%) had features of lymphocytic colitis. One patient had spontaneous colonic perforation that required surgical intervention. Colitis symptoms recurred in 7 patients (9%) after initial improvement. Patients who received nab-paclitaxel developed GI toxicity earlier (P=0.003), required colitis-related hospitalization more frequently (P=0.005), and received intravenous fluids more frequently (P=0.025), compared with patients who received other taxanes.Conclusions:Taxane-related colitis can present with significant inflammation on colonoscopy, and in a minority of patients as microscopic colitis. Taxane-induced colitis, although uncommon, can lead to ICU admission and colonic perforation.

Spontaneous Perforation of Sigmoid Colon Due to Chronic Constipation

Spontaneous Perforation of Sigmoid Colon Due to Chronic Constipation

Spontaneous Sigmoid Colon Perforation Based on Endometriosis in Term Pregnancy Case Report

The case report describes a woman with acute, spontaneous sigmoid colon perforation based on deep endometriosis in advanced stage of pregnancy. The 33-yearold white woman was admitted to our clinic at 37+6 weeks of pregnancy with symptoms of increasing abdominal pain successively changing the site of maximum. Due to suspicion of acute appendicitis, acute caesarean section, sigmoid resection and end-to-end anastomosis, appendectomy was performed. Spontaneous perforation associated with intestinal endometriosis in pregnancy is scarcely reported, some seven cases have been published in the English literature. To the best of our knowledge, this is the second case report of sigmoid colon perforation due to endometriosis during pregnancy.

Spontaneous perforation of sigmoid colon in a child with acute lymphoblastic leukemia

Introduction. Perforation of the sigmoid colon is rare in children and its descriptions in medical literature are infrequent. Case Outline. In a 13-year-old boy with acute lymphoblastic leukemia, a ten-month course of chemotherapy was accompanied by many complications: parasitic infestation (Enterobius vermicularis), lung candidiasis, esophageal candidiasis, steroid diabetes, anaphylactoid reaction to L-asparaginase, febrile neutropenia, mucositis, anemia, thrombocytopenia, enterocolitis, and respiratory distress syndrome. During reinduction treatment, consisting of dexamethasone, vincristine, doxorubicin, and crisantaspase, he complained of abdominal pain and, upon radiographic examination, was found to have pneumoperitoneum. Because of suspicion of abdominal hollow organ perforation, he was subjected to explorative laparotomy, which yielded the diagnosis of perforation of the sigmoid colon. Conclusion. After an extensive review of the published reports on sigmoid perforation, all associated conditions that could possibly induce perforation ? such as Hirschsprung?s disease or foreign body ? were systematically excluded in our patient. Although typhlitis was the first diagnostic hypothesis, this was excluded by intraoperative findings, histopathology, and perforation site. To the best of our knowledge, this is the first report of a spontaneous perforation of the sigmoid colon in a child with acute lymphoblastic leukemia.