A case of sigmoid colon perforation presenting with pneumomediastinum

Abstract

A 62-year-old woman had developed polymyositis 12 years previously and had taken oral steroids. Chest and abdominal computed tomography showed pneumomediastinum and free air in the abdominal cavity. Although a colon perforation was suspected, the perforation site could not be identified on the image. In addition, a diagnosis of oesophageal rupture could not be excluded from the findings of pneumomediastinum. After general anaesthesia, an upper gastrointestinal endoscopy was performed before surgery. Because there was no obvious perforation in the oesophagus, a laparotomy approach was used. A perforation was found on the mesentery side of the sigmoid colon, and a perforation of the sigmoid colon’s diverticulum towards the mesentery was diagnosed. A Hartmann’s procedure was performed. Colon perforations are rarely associated with pneumomediastinum. Preoperative endoscopy is useful to help diagnose and determine the surgical procedure if an obvious perforation cannot be identified.

Delayed perforation after cold snare polypectomy for small colonic polyps in a patient receiving oral corticosteroids

“…It is also important to note that when the endoscopists resected the polyps, they felt that the polyps were resected more easily than usual, possibly indicating weakness of the intestinal wall. However, other reports describe perforations that might have been caused by tissue ischemia, such as vasculitis 9,10 . In our case, vasculitis was found in the resected specimen, although no thinning of or abscesses within the intestinal wall existed.…”

“…We experienced a case of delayed perforation from CSP in a corticosteroid-treated patient with vascular fragility and the presence of vasculitis. It is possible that some patients on corticosteroid therapy may have a special pathology, such as that of this case, sigmoid colon perforation, 9 or jejunal perforation, 10 but it is difficult to confirm in advance whether all patients undergoing colonoscopy have a possible special pathology. To avoid such rare adverse events, clinicians should be wary of patients undergoing corticosteroid therapy.…”

“… 8 Other reports describe perforations that might have been caused by tissue ischemia, such as vasculitis. 9 , 10 A case of unusual jejunal perforation in a patient undergoing corticosteroid treatment described marked hemorrhage and necrotic changes in the mucosa and hemorrhage and inflammatory exudates in the serosa at the perforation site. In that case, pathologic examination of the intestinal vessels showed mesenteric small‐vessel vasculitis and vascular thrombosis with perivascular inflammatory cell infiltration.…”

“…According to a meta‐analysis, corticosteroids increase the risk of bleeding or perforation by 40% 8 . Other reports describe perforations that might have been caused by tissue ischemia, such as vasculitis 9,10 . A case of unusual jejunal perforation in a patient undergoing corticosteroid treatment described marked hemorrhage and necrotic changes in the mucosa and hemorrhage and inflammatory exudates in the serosa at the perforation site.…”

Diffuse subcutaneous emphysema: a clinical challenge

“…Retroperitoneal perforation on the mesentery side is rare and accurate diagnosis may be challenging, especially in the absence of typical symptoms due to peritoneal irritation. Diffuse subcutaneous emphysema spreading up to the thorax may occasionally occur before obtaining the appropriate diagnosis 2–4 . The mechanism of spread follows the anatomic connections between the posterior pararenal space and the diaphragmatic hiatus.…”