Spontaneous Colonic Perforation Research Articles

Spontaneous perforation of pelvic colon

Spontaneous perforation of pelvic colon

Meconium peritonitis; report of a case due to spontaneous intrauterine perforation of the transverse colon, with a brief review of the literature.

Meconium peritonitis; report of a case due to spontaneous intrauterine perforation of the transverse colon, with a brief review of the literature.

Spontaneous Colonic Perforation without Dilatation in a Patient with Ulcerative Colitis (UC) and the Role of Imaging Modalities in the Diagnosis of Colonic Perforation

Describe an uncommon complication in a patient with UC. 64 year old, non-compliant female, with an 8-year history of UC currently on Asacol presents to the EC with 3 days of flue like symptoms, intermittent lower abdominal pain, nausea, vomiting, and diarrhea. Physical examination was unremarkable except for mild abdominal distention and mild tenderness in the lower quadrants. Labs showed a WBC 22.4, Hg 11.0, BUN 17, and Cr 2.0. Acute abdominal series (AAS) was worrisome for distal mechanical SBO without free air. Clinical condition deteriorated as the patient was being prepped for CT. CT abdomen and pelvis 6 hours following the AAS showed severely dilated bowel loops with inflammatory changes in the small bowel mesentery and evidence of perforation with free fluid without again free air. Patient underwent exploratory surgery, revealing a perforated sigmoid colon. Free colonic perforation without dilatation in patients with UC is uncommon. Free perforation occurred in only 7/702 patients with UC (1%) without toxic dilatation seen at Mount Sinai Hospital (1960–1981). These 7 patients represented 30% (7/23) of all colonic perforations seen in patients with UC. Classic physical signs of peritonitis were absent in 6/7 patients. All had a marked deterioration in general condition after perforation. Mortality was high (57%). Comparatively longer histories of colitis, prolonged current attacks, and slightly greater delays between presumed perforation and operation were characteristics of these patients. Several studies have evaluated the use of various imaging studies in the diagnoses of visceral perforation. One study showed that combined radiography, US and CT showed signs of perforation in 71% of cases. When free air was absent (1/3 of cases), free intraperitoneal fluid was the only radiological finding. Another study showed that CT demonstrated the presence of free intraperitoneal gas in more patients than an AAS (92% vs. 74%). Possibility of free perforation in UC must be considered in fulminating cases, even in the absence of colonic dilatation. Careful clinical monitoring and early surgical intervention may be the keys to reducing mortality. AAS is still the primary tool to evaluate for visceral perforation. Free air when present may be detected in nearly 100% of cases. When there is no free air detected and symptoms persist, CT should be performed after at least 6 hours interval to allow the radiological picture to change.

Management of spontaneous colonic perforation in ehlers-danlos syndrome type IV

A 14-year-old girl with a family history of fatal colonic rupture, presented with a 2-day history of abdominal pain and signs of peritonitis. At laparotomy, a full-thickness perforation of the sigmoid colon was found, which was exteriorized as a loop colostomy. Subsequently, molecular studies of the patient’s cultured fibroblasts found a point mutation in the COL3A1 gene, confirming a diagnosis of Ehlers-Danlos syndrome type IV (EDS-IV). Four and a half years later, a total abdominal colectomy and ileoproctostomy were performed, restoring intestinal continuity. At 5 years follow-up, the patient has had no further complications. Although spontaneous colonic perforation is a well-reported manifestation of EDS-IV, a consensus on the surgical management of this complication in EDS-IV has yet to be determined. Given the high rate of reperforation in EDS-IV when the colon is left in place and the low incidence of reported small bowel and rectal perforations, subtotal colectomy is a reasonable treatment. Primary anastomosis and avoidance of an end-ileostomy was possible in this young patient, with no evidence of anastomotic leakage nor reperforation to date. Lifelong close follow-up should be continued in these patients, because the natural history of this anatomy in EDS-IV is not known.

Use of Porcine Small Intestinal Submucosa in Ehlers-Danlos Syndrome Type IV

Ehlers-Danlos syndrome (EDS) Type IV results in inadequate production of type III collagen and can lead to devastating vascular, gastrointestinal, and uterine complications. A case is presented of spontaneous colonic perforation in a patient with EDS Type IV complicated by multiple intestinal fistulas managed with porcine small intestinal submucosa. Early success with this technique would suggest additional applications in a variety of complicated gastrointestinal problems.

The Ehlers-Danlos Specter Revisited

Ehlers-Danlos type IV is a major concern to vascular surgeons because it is often associated with spontaneous hemorrhage from arteries containing decreased type III collagen. Five members of a family with Ehlers-Danlos type IV and a review of another family of five with Ehlers-Danlos type IV are reported. Evaluation of the recent family included clinical evaluation as well as assay of collagen production. The age range of the three involved females and two males was 7 to 52 years. The father of the affected family had a spontaneous colon perforation at age 39. His son, at age 27, had a spontaneous rupture of the iliac artery. Revascularization was accomplished with difficulty. His daughter had a large cerebral bleed. Two granddaughters, ages 7, have not had any bleeding or aneurysmal events. The amount of type III collagen was only 10% of normal in the patient with the iliac artery rupture. The three females all exhibited similarly low levels of type III collagen. The father's type III collagen level was not sufficiently low to confirm Ehlers-Danlos type IV, although he had a spontaneous colon perforation. In the other Ehlers-Danlos type IV family of five, the three surviving members had type III collagen levels as low as 5% of normal. Two family members died after spontaneous iliac rupture at ages 24 and 33. Both families exhibited an autosomal dominant inheritance pattern. Ehlers-Danlos type IV remains a challenging problem for vascular surgeons. It is transmitted as an autosomal dominant inheritance with a high degree of penetrance. Spontaneous arterial and intestinal perforations should alert the clinician to the possibility of Ehlers-Danlos type IV. Patients should be evaluated noninvasively. Arterial repairs may not be successful in these patients because the vessels are extremely friable. Assays of collagen production are advisable in establishing the diagnosis.

DIFFUSE DIVERTICULOSIS OF COLON WITH SPONTANEOUS PERFORATION IN A CHILD

128 Colonic diverticulosis is commonly seen in adults, frequently involving the sigmoid colon. Diffuse colonic diverticulosis has not been reported in pediatric population. We report a 10 year-old, white female, referred for a two week history of vomiting and severe abdominal pain. There was no history of chronic constipation, fever, diarrhea or weight loss. The patient's prior history was significant for spontaneous colonic perforation that required colostomy and resection of sigmoid colon (6cm) two years prior. An additional short segment of colon was resected due to "muscular weakness" during reanastomosis three months later. Further evaluation included a suction rectal biopsy which revealed presence of ganglion cells. No underlying etiology was determined for the colonic perforation. She had been asymptomatic until this hospitalization. An upper gastrointestinal series with small bowel follow through was normal, however a colonoscopy revealed multiple diverticula (40 or more) throughout the colon. An elective abdominal colectomy was performed due to potential risk of perforation. Gross and histological examination of the resected colon showed multiple diverticula with loss of muscularis propria and fibrous replacement. Diffuse colonic diverticulosis (congenital or acquired) should be considered in children with spontaneous colonic perforations. The awareness and prompt recognition of diverticulosis could prevent potential life threatening gastrointestinal complications.

Parental mosaicism for a point mutation in a type III collagen (COI3AI) allele produces Ehlers-Danlos type IV (EDS4) in heterozygous offspring

We describe a family with EDS type IV in which the clinically unaffected mother of two affected children is mosaic for the mutation in the COL3A1 gene. The proband, a 27 year old male, presented with a spontaneous retroperitoneal hemorrhage and multiple arterial pseudoaneurysms. At the age of 20, he had a spontaneous colonic perforation. His sister had a cerebral hemorrhage at 23, spontaneous splenic rupture at 26, recurrent paleuar dislocations and delayed wound healing. Skin fibroblasts from the proband secreted diminished amounts of type III collagen precursors and retained overmodified proα1(III) chains, consistent with a defect in one COL3A1 allele. SSCP screening and sequence analysis of cDNA identified a point mutation resulting in a substitution of Asp for Gly at amino acid 493 within the triple helical domain of the proα1(III) chain of type III collagen. The mutation eliminated an AvaII restriction site. Amplification and digestion of DNA from the proband's sister showed the identical mutation. Paternal mosaicism was initially suspected as the father had a history or spontaneous rupture of a pancreatic duct cyst. However, digestion of paternal white blood cell DNA with AvaII revealed a normal restriction pattern in the father, but evidence for the presence of the mutation in a population of cells in the mother. A small number of families have now been identified in which one asymptomatic parent was mosaic which indicates that this risk must be considered in counseling parents after the identification of an affected child.

Colon Perforation After Lung Transplantation

Colon perforation has been previously described after solid organ transplantation. Since the inception of the lung transplant program at the University of Colorado 60 isolated lung transplantations have been performed. Four of these patients have suffered spontaneous colonic perforation. The case history of each lung transplant patient with a colon perforation and the literature were reviewed. An increased incidence of colon perforation in lung transplant patients was identified. Diverticulitis was found to be the predominant cause, and an association with steroids was noted. The two deaths in this series were in patients receiving high-dose steroids in whom invasive Aspergillus infections developed. Careful screening of the gastrointestinal tract before transplantation is advocated. A steroid-sparing immunosuppressive regimen is recommended. All lung transplant patients with abdominal complaints require an aggressive work-up, and surgeons should have a low threshold for laparotomy. Conservative surgical principles, including resection of the perforated segment of colon and proximal end-colostomy rather than primary anastomosis, are necessary for the optimal outcome.

Spontaneous Colonic Perforation

Spontaneous Colonic Perforation

The choice of surgical procedure for peritonitis due to colonic perforation.

Because the choice of surgical procedure for colonic perforation is still matter of debate, we retrospectively studied peritonitis caused by spontaneous colonic perforation to assess predictors of mortality and the safety of primary resection and anastomosis. Case series. We investigated one hundred thirty-six consecutive patients with peritonitis due to colonic perforation who were surgically treated in an emergency surgery department. Eighty-one patients underwent primary resection and anastomosis, thirty-three underwent the Hartmann procedure, and twenty-two had simple colostomy. The seriousness of peritonitis was assessed in terms of Hinchey stage, the Mannheim Peritonitis Index (MPI), and the acute physiology and chronic health evaluation (APACHE) II score. The overall mortality rate was 20%. The APACHE II scores and MPIs were lower for survivors than for nonsurvivors. The mortality rate was 6% for primary resection and anastomosis, 30% for the Hartmann procedure, and 59% for simple colostomy, but the severity scores were significantly lower in patients who underwent primary resection than those of patients who had the Hartmann procedure and colostomy, respectively. Since primary resection and anastomosis has been shown to be safe, we suggest that is is proper, even in the presence of peritonitis. In spite of this, we conclude that the surgical procedure does not influence outcome but that the mortality rate is related to the severity of peritonitis, accurately measured by APACHE II score and MPI.

Surgical complications of the hemolytic-uremic syndrome

Hemolytic-uremic syndrome (HUS) of childhood is a triad of acute hemolytic anemia, thrombocytopenia, and acute renal failure associated with a gastrointestinal prodrome. From 1977 to 1988, 134 patients with HUS were admitted to this institution. All patients presented with abdominal pain and diarrhea, which was virtually always bloody. Seventy-eight patients (60%) required dialysis. Five patients died (4%). One patient died as a result of colon perforation, the other four patients died of other nonsurgical complications of HUS. Three patients underwent exploratory laparotomy. One patient had a hemoperitoneum from mesenteric and transmural bleeding of the entire intraabdominal colon. Another patient had undergone surgery elsewhere for presumed intussusception with pancolitis found at exploration. Fourteen days postoperatively, he had a spontaneous perforation of the transverse colon. The third patient presented with pancolitis and perforation of the transverse colon. Despite surgical intervention he died on the sixth postoperative day. One other patient was treated conservatively for pancreatitis, which developed 3 weeks after her presentation with HUS. Complications requiring surgical intervention in HUS are rare, potentially lethal, and usually involve the colon.

Perforation of the colon in a 15-year-old girl with Ehlers-Danlos syndrome type IV

A 15-year-old girl presented with severe fecal peritonitis due to a large spontaneous colonic perforation. The sigmoid colon was the site of a cluster of white serosal lesions with omental adhesions, of an appearance identical to that of the edges of the perforation. Her father had died at 30 years of age of spontaneous rupture of an iliac artery aneurysm, preceded by rupture of a splenic artery aneurysm and a spontaneous carotid-cavernous fistula. The clinical diagnosis of Ehlers-Danlos syndrome type IV was made, and confirmed by demonstrating that the patient's cultured fibroblasts are not producing or secreting type III collagen. Spontaneous perforation of the colon is a well-described complication of this syndrome, with a high incidence of recurrence. We recommend total abdominal colectomy to minimize the latter possibility.

Colonic complications in renal transplant recipients.

Complications involving the colon occurred in 28 of 325 patients who received renal transplants. Pseudomembranous colitis, the most common complication, affected 15 patients, two of whom required surgery. Three instances of diverticulitis were complicated by free perforation in two cases, and by colovesical fistula in one. Appendicitis occurred in two cases. The other complications were hemorrhage (from diverticulosis or angiodysplasia), nonspecific colitis, and ischemic colitis. Spontaneous colonic perforation did not occur. Two thirds of the colonic complications occurred within 30 days after transplantation. All cases of colon perforation, however, occurred later than one month after transplantation. It is concluded that pseudomembranous colitis is the most common colonic complication in renal transplant recipients, that it usually occurs early, and that it carries a good prognosis. Colonic perforations occurred later in this series and were treated successfully. All cases of ischemic colitis were part of terminal multiorgan system failure.

Occlusion of a hepatic arterial aneurysm with gianturco coils in a patient with the Ehlers-Danlos syndrome

Successful transcatheter occlusion of a proper hepatic arterial aneurysm in a patient with type IV Ehlers-Danlos syndrome is reported. This patient also had multiple, small intrahepatic arterial aneurysms, stenosis, and vascular occlusions. A spontaneous colonic perforation brought this patient to medical attention.

Colonic perforation in renal transplant patients.

Review of 713 renal transplant patients at the Medical College of Wisconsin yielded 17 (2.3%) with spontaneous colon perforation. The cause seemed to be related to nonocclusive ischemia in the majority of cases (nine). The sigmoid colon was the most common site of perforation (nine cases). The early detection of colon perforation suspected on radiographic examination was associated with improved survival statistics.

Spontaneous colonic perforation secondary to cytomegalovirus in a patient with acquired immune deficiency syndrome

We report a case of spontaneous perforation of the transverse colon due to multiple ulcerations infected with cytomegalovirus (CMV) in a patient suffering from acquired immune deficiency syndrome (AIDS). The authors recommend a thorough clinical and laboratory search (including tissue diagnosis, when possible) for evidence of CMV infection in immunosuppressed patients with new or poorly healing GI ulcerations, who are otherwise at risk for CMV infection, e.g., patients with AIDS. When performing surgery on AIDS patients, operating room protocol should be identical to that used for hepatitis B virus patients.

Gastrointestinal Tract Bleeding of Unknown Origin

It is becoming increasingly apparent that patients with chronic renal failure are at increased risk for developing a variety of gastrointestinal (GI) tract complications. Initially, it seemed that such complications were predominantly confined to those patients who underwent renal transplantation. More recently, patients receiving longterm hemodialysis have been found to have numerous GI tract disorders and, in particular, disorders of the large intestine, including diverticulosis and diverticulitis,¹spontaneous colonic perforation,²ischemic colitis,³and discrete colonic ulceration.⁴ <h3>See also p 303.</h3> The article by Adams et al entitled "Lower Gastrointestinal Tract Dysfunction in Patients Receiving Long-term Hemodialysis" in this issue of theArchives(p 303) describes a group of patients receiving long-term hemodialysis with yet another such disorder—colonic pseudoobstruction. Juxtaposed against a similar group of patients receiving hemodialysis in whom colonic perforation had developed, both as a result of mechanical factors and spontaneously, the clinical importance of

Colonic Disease in Patients Receiving Hemodialysis

It is becoming increasingly apparent that patients with chronic renal failure are at increased risk for developing a variety of gastrointestinal (GI) tract complications. Initially, it seemed that such complications were predominantly confined to those patients who underwent renal transplantation. More recently, patients receiving longterm hemodialysis have been found to have numerous GI tract disorders and, in particular, disorders of the large intestine, including diverticulosis and diverticulitis, 1 spontaneous colonic perforation, 2 ischemic colitis, 3 and discrete colonic ulceration. 4 See also p 303. The article by Adams et al entitled "Lower Gastrointestinal Tract Dysfunction in Patients Receiving Long-term Hemodialysis" in this issue of theArchives(p 303) describes a group of patients receiving long-term hemodialysis with yet another such disorder—colonic pseudoobstruction. Juxtaposed against a similar group of patients receiving hemodialysis in whom colonic perforation had developed, both as a result of mechanical factors and spontaneously, the clinical importance of

Spontaneous perforation of the colon a potential complication of chronic renal failure

A case of spontaneous colonic perforation in a patient receiving chronic hemodialysis is described. Chronic progressive constipation leading to stercoraceous ulceration may have been the precipitating event.