Perforated diverticulitis of the sigmoid colon causing a subcutaneous emphysema

Abstract

INTRODUCTIONAlthough diverticular disease of the colon is frequent, perforated diverticulitis causing subcutaneous emphysema is a uncommon entity. We wish to present this extremely rare case of perforated colonic diverticulum in the subcutaneous tissue, which is the first one that we have encountered in our practice, along with the accompanying diagnostic and therapeutic issues and a review of the literature.PRESENTATION OF CASEWe report the case of an 83-year-old man who admitted to the emergency room due to an abdominal subcutaneous emphysema. Physical examination revealed a severe subcutaneous emphysema especially in the left iliac fossa and abdominal pain. An urgent contrast enhanced abdominal CT scan showed multiple diverticula in the sigmoid colon and multiple air bubbles in the subcutaneous tissue. The exploratory laparotomy identified a perforation of diverticular in subcutaneous tissue. Forty centimeters of colon were resected. The subcutaneous emphysema resolved without specific treatment. The postoperative period was uncomplicated.DISCUSSIONSubcutaneous emphysema of anterior abdomen wall is an obvious physical sign but its etiology is complex to determine and may be potentially lethal. The pathophysiological mechanism involved is the emergence of a pressure gradient between the peritoneum and surrounding structures, causing rupture of the anterior abdominal wall, allowing gas from a perforation to diffuse along tissue planes.CONCLUSIONThis physical sign may be of especial value in elderly patient groups amongst whom perforation may be less clinically obvious. General surgeons should bear in mind this rare complication of colonic diverticulosis.

Subcutaneous emphysema of the neck, chest, and abdomen as a symptom of colonic diverticular perforation into the retroperitoneum

“…Colonic diverticula are small mucosal herniations through points of reduced resistance in the muscular wall of the colon. At these locations, arterioles penetrate the colonic wall which is overgrown with fat tissue [ 1 ]. Colonic diverticula affect people over 50 years of age and constitute one of the most common human diseases.…”

Perforated diverticulitis of the sigmoid colon revealed by a perianal fistula

“…The most common complication of colonic diverticulosis is acute diverticulitis. The disease is usually silent and must be suspected in patients presenting with crampy abdominal pain, altered bowel habits, anemia, chronic abdominal pain or discomfort [3] .…”

Left Colon Diverticulitis Presenting as Perforated Lumbar Abscess: A Case Report and Review of the Current Literature

“…However, it can also appear with nontypical signs, through complications such as chronic abscesses, the creation of fistulae, and bowel obstruction. Therefore, cases have been reported that presented with colovesical and colovaginal fistulae [ 6 ], perianal fistulae [ 7 ], abscess formation on the abdominal wall [ 1 ], the thigh [ 6 ], or the renal fossa during end-stage renal disease [ 8 ], subcutaneous emphysema [ 9 ], and a perforation in a lumbar hernia [ 10 ].…”

“…Abdominal CT is the imaging examination of choice, as it sets the definite diagnosis, shows the extent of abdominal inflammation, and excludes any other causes of acute abdominal pain [ 9 ]. In our case, a CT was immediately performed after the lumbar abscess drainage because, in combination with the abdominal pain, the X-ray findings, and the medical history, a clinical suspicion of diverticular perforation was set.…”