EXTRAPERITONEAL PERFORATIONS OF THE GASTROINTESTINAL

Transcription

1 \OL. 10,, No. EXTRAPERITONEAL PERFORATIONS OF THE GASTROINTESTINAL TRACT* By MALCOLM C. HILL, M.B., WILLIAM P. BIEBER, M.D., ROBERT L. KOCH, M.D., and WALTER COULSON, M.D. 1/1 OST roentgenologists are constantly _1_v1 watchful for free or intraperitoneal air on reviewing noentgenograms of the abdomen. Intrapenitoneal air is detectable in small amounts in roentgenograms obtamed in the erect on decubitus positions and in larger amounts in the recumbent. Seldom is this intrapenitoneal air overlooked. Radiologists who have reviewed SAN FRANCISCO, CALIFORNIA roentgenograms on diagnostic retropenitoneal gas studies are familiar with the appearance of extraperitoneal air (or gas). It is frequently overlooked, however, when it is not expected, particularly when ab- (lominal roentgenograms are obtained be cause of abdominal pain. At that time the attention of the roentgenologist may be diverted by numerous gas-filled loops of bowel. There have been recent reports of extrapenitoneal perforations of the duodenum and rectum. However, no radiologic and only a few other references have appeared in the last 20 years pertaining to extrapenitoneal perforations of the bowel between the ligament of Treitz and the rectum. The purpose of this report is to present 5 cases of extrapenitoneal perforation of the bowel together with the clinical and roentgen features. In 3 of these, extrapenitoneal perforation was of the colon (above the rectum). REPORT OF CASES CASE 1. A 66 year old woman was admitted to the hospital with left lower abdominal cramps. She had had some left lower quadrant discomfort for 6 weeks, but this had recently become worse. For the 3 days preceding admission, diarrhea had been present. On admission the patient s temperature was 100#{176}F. The abdomen was distended and tender and a vague mass in the left abdomen was thought to be a fecal-filled colon. The results of the stool cxamination for ova and parasites were negative. The clinical diagnosis was diverticulitis or carcinoma of the left colon. Plain roentgenograms of the abdomen were obtained (Fig. i, A and B). One week later a barium enema cxamination was performed (Fig. ic). The patient was treated by a diverting transverse colostomy and retroperitoneal drainage, and recovered satisfactorily. The barium enema cxamination was repeated 7 months later (Fig. id). Following this examination, the left colon was explored surgically. A small portion of the left colon, which the surgeon considered slightly thickened, was resected, but histologically this proved to be of normal colon. The colostomy wound was eventually closed and continuity of the bowel was re-established without complications. Although the cause of the perforation was not clearly established, the surgeon expressed the opinion that it was the result of a perforated solitary diverticulum, not identified at the exploration 7 months later. CASE II. A 67 year old woman was admitted to another hospital on March I, 1964 with sudden onset of lower abdominal pain and a temperature of 103#{176}F. Clinically the condition was diagnosed as sigmoid diverticulitis and the patient was treated with antibiotics which resulted in only temporary improvement. On March 6, 1964, she was transferred to the San Francisco General Hospital. On examination the patient was confused and had a temperature of 101#{176} F. Because of generalized abdominal distention with guarding and rebound tenderness over the lower abdomen, plain abdominal roentgenograms were obtained (Fig. 2, A and B). Laparotomy disclosed marked inflammation of the sigmoid colon, which was covered by a fibrinous exudate. Extensive gas in the sigmoid mesentery extended into the retroperi- * From the Department of Radiology, University of California School of Medicine and the San Francisco General Hospital, San Francisco, California. 315

2 316 1\I. C. Hill, W. P. Bieber, R. L. Koch and W. Coulson OCTOBER, 1967 I 1G. 1. Case i. and B) Plain roentgenograms of abdomen. (A) Supine roentgenogram shows that the psoas shadow and the left extraperitoneal fat line are obliterated. Numerous small shadows of gas surround the upper descending colon. (B) Erect roentgenogram showing left upper quadrant. No free or intraperitoneal gas is seen. The small gas bubbles surrounding the upper descending colon are better shown. Note 0 0

3 VOL. 101, No. 2 Perforation of the Gastrointestinal Tract G. 2. Case II. (1) Supine and (B) erect abdominal roentgenograms. Numerous loops of 1)0th small and large bowel are distended by gas. No intraperitoneal gas is present. Retroperitoneal gas outlines both kidneys and both adrenal regions. The opacity seen to the left of the third lumbar vertebra in the supine roentgenogram and projected over the left ilium in the erect roentgenogram was a flashlight bulb that the patient had ingested. toneal space. No pus was noted in the retroperitoneum, however, and the gas was thought to be the result of a perforation of the sigmoid and not of gas-producing organisms. A diverting transverse colostomy was performed and the marked distention of the small bowel was treated by decompression with a Leonard tube. A foreign body, which had been observed on the roentgenograms, proved to be a small flashlight bulb in the small bowel. Apparently the patient had ingested this bulb during her confused state. Although the sigmoid was not explored, the perforation was possibly caused by an additional ingested foreign body in the sigmoid. Postoperative bron chopn eumon i a developed and the patient died in cardiovascular collapse 21 days after the operation. Necropsy was not performed. CASE III. A 6i year old man was admitted to the hospital with a 6 day history of lower abdominal pain and bloody stool. The patient had noted increasing constipation for the previous 6 months. On physical examination, a tender mass was palpated in the left lower abdominal quadrant. The results of laboratory studies were normal except for a white blood cell count of ii,6oo. Abdominal roentgenograms were ohpleural fluid on the left and atelectasis in the base of left lung. The extraperitoneal perforation was overlooked on the initial interpretation of these roentgenograms. (C) Barium enema roentgenogram 7 days later. Barium has extravasated into the retroperitoneal space from a perforation in the lower descending colon. (The, densities in the right upper quadrant represent gallstones.) (D) Barium enema roentgenogram 7 months later. The colon is opacified from the rectum to the transverse colostomy. A small amount of barium remains in the retroperitoneal space from the previous perforation. No new extravasation has occurred.

4 M. C. Hill, W. P. Bieber, R. L. Koch and W. Coulson 318 OCTOBER, 167 tamed (Fig., A and B). On the first hospital day an abscess of the left lower abdominal wall was incised and drained. On culture of the abscess, coliform organisms were obtained. A laparotoniy on the tenth day revealed a mass in the sigmoid colon. A left colectomy was performed. The pathologic diagnosis was that of a perforating carcinoma of the sigmoid colon. CAsE IV. A 7 year old woman was admitted with diffuse abdominal pain of 12 hours duraflon. Nausea and intolerance to fatty food had been noted for the previous 3 months. The physical examination disclosed a temperature of 100#{176} F. The abdomen was slightly distended, with tenderness and guarding in its upper pornon. Clinically, the condition appeared to be otie of acute cholecvstitis. A nasogastric tube was passed and suction begun. An upright abdominal roentgenogram (not shown) revealed no evidence of free air. An intravelious cholangiography was performed (l ig., A and B). On delayed roentgenograms (not shown) a normal common duct and gallbladder were apparent. The patient was given intravenous fluids and antibiotics, which improved the abdominal signs temporarily. The clinical impression was changed to that of possible bacterial endocardiris and, while this was being investigated, the patient suddenl became hypotelisive and died. On necropsy, a perforated ulcer was preselit in the duodenum 2 cm. distal to the pylorus, with a focal area of organizing peritonitis around the ulcer. CAsE V. A 2$ year old man was involved in an automobile accident in which the upper abdomen was struck by the steering column. Almost immedi atel v, severe, gen aized abdominal pain was experienced. On examination one hour after the accident, diffuse abdominal tenderness was present. No masses were pal- 11G. 3. Case In. Plain abdominal roentgenograms, left lower quadrant. (4) Gas in the sigmoid is displaced by a mass (2 large arrows). A collection of gas is lateral to the sigmoid and in the region of the mass ( small arrows). (B) Tangential roentgenogram. The collection of gas (arrow) is seen to he extraperitoneal in the abdominal wall. B

5 \OL. ioi, No. 2 Perforation of the Gastrointestinal Tract lic.. Case iv. Abdominal roentgenograms obtained during an intravenous cholangiography. The biliary duct system has not yet opacified. Note the unusual position of the nasogastric tube, which appears coiled in the second portion of the duodenum with the tip of the tube extending toward the right. In zi an unusual collection of gas is seen near the tip of the tube (arrows). In B the tube has l)een outlined in ink to better demonstrate it over the spine. The right psoas shadow is obliterated. The diagnosis of an extraperitoneal perforation of the duodenum was not made on the initial interpretation of these roentgenograms. pable and Peristalsis was absent. The abdomen became board-like within 2 hours. Roentgenograms of the abdomen obtained in the interval gave evidence of retroperitoneal gas (Fig. 5). On laparotomv after these roentgen examinations, a 2.#{231}cm. retroperitoneal perforation was found in the third portion of the duodenum. The perforation was repaired and a drain left in place. Recovery was satisfactory and the patient was discharged on the thirteenth postoperative day. 1)1 S CUSS ION The cli cal en titv of su hcu taneous emphvsema secondary to perforation of the gastrointestinal tract has long been known. The term, surgical emphysema, is often applied. l o be clinically apparent, large amounts of gas need to be present which will often need to dissect for a consi(lerable distance from the site of perforation. Thus, clinical evaluation is less likely to be accurate than are roentgen studies in the detection ofextraperitoneal perforations of the intestinal tract. Oetting et al.7 reviewed the world literature for cases of subcutaneous emphysema second any to gas al perforation from 1853 to 1953 and collected 34 cases. The roentgen findings were not described. The sites of appearance of the emphysema were designated as the neck, anterior abdominal wall, and perineum. The authors noted correlation between the site of intestinal perforation and the appearance of the emphysema. Perforations of gastric and duodenal ulcers presented an emphysema in the neck. Emphysema from perforations of the colon and small bowel appeared in the anterior abdominal wall, and anorectal lesions caused emphysema in the perineum. In 2 additional cases, subcutaneous air was seen on roentgenogranis in the anterior abdominal wall of one and in the netroperitoneal space in the other. The

6 320 M. C. Hill, W. P. Bieber, R. L. Koch and W. Coulson OC10BER, 1967 lic.. Case v. Upright abdominal roentgenogram. Retroperitoneal gas outlines the right kidney. No evidence is seen of intraperitoneal gas under the diaphragm. The right psoas shadow is obliterated. roen tgen appearance in cx traperi toneal perforations of the duodenum and rectum has been described several times. Spenling and Rigler,9 in 1937, described retropenitoneal gas in traumatic rupture of the duodenum. Jacobson and Carter4 reviewed 19 cases of intestinal rupture resulting from nonpenetrating abdominal injury. Most of these ruptures were found proximal to the ligament of Treitz and some of the perforations were extrapenitoneal. Few reports have appeared of the roentgen findings of extrapenitoneal perforations of the bowel that were situated between the ligament of Treitz and the nectosigmoid junction. Lewis6 described a single case of spontaneous perforation of the sigmoid colon in which a large amount of retnopenitoneal gas was seen on abdominal roentgenograms. In the present report, cases of extrapenitoneal perforation of the intestinal tract are described. In Case i a perforated solitary diventiculum of the descending colon may have been the cause. In Case ii, an ingested foreign body was suspected.2 The perforations in Cases iii, iv, and v, were caused respectively b carcinoma, peptic ulcer, and traum a. Extrapeni toneal perforations may occur from retroperitoneal portions of the gastrointestinal tract.58 Such instances are illustrated in the descending colon b Case and in the retroperitoneal duodenum by Cases iv and v. They may occur also from intrapenitoneal portions of the gastrointestinal tract by perforation into the niesenterv, with extraperitoneal dissection, as in Cases II and III. \Vhen the hole in the bowel straddles the junction of an intraperitoneal and extraperitoneal portion of the gastrointestinal tract, intraperi toneal and extraperi toneal perforations iii av occur simultaneously. These cases do not ordinarily present diagnostic problems, however, and the clinical and roentgen signs of in traperi toneal perforation are usually readily apparent and lead to surgical exploration. S U 1 1 AR Extrapenitoneal perforations of the gastroi n testi nal tract, although uncommon, may be fatal if not recognized. The clinical and roentgen features of 5 cases of extraperitoneal perforation are described. In all, one or more of the following roentgen signs were seen: extrapenitoneal gas, obliteration of normal extrapenitoneal fat lines, and abnormal position of nasogastric tube. Usually an alert roentgenologist will be able to provide the diagnosis earlier than can the clinician. Malcolm C. Hill, M.B. Department of Radiology University of California San Francisco Medical Center San Francisco, California REFERENCES 1. GOULD, R. J., and THORWARTH, W. T. Retroperitoneal rupture of duodenum due to blunt non-penetrating abdominal trauma. Radiology, 1963, So, GUN N, A. Intestinal perforation due to swallowed fish or meat bone. Lancet, 1966, z, HILL, M. C. Roentgen diagnosis of duodenal injuries. Ass. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1965, 94, V

7 VOL. ioi, No. 2 Perforation of the Gastrointestinal Tract 32! 4. JACOBSON, G., and CARTER, R. A. Small intestinal rupture due to non-penetrating abdominal injury: roentgenological study. AM. J. ROENT- GENOL., RAD. THERAPY & NUCLEAR MED., i5i, 66, KLEIN, R. R., and SCARBOROUGH, R. A. Traumatic perforations of rectum and distal colon. Am. 7. Surg., 1953, 76, LEwis, E. C. Spontaneous perforation of colon associated with gross surgical emphysema. Brit. 7. Surg., 1963, 50, OETTING, H. K., KRAMER, N. E., and BRANCH, W. E. Subcutaneous emphysema of gastrointestinal origin. Am. 7. Mcd.,1955, 19, SHACKLETON, M. E. Perforation of duodenal diverticulum with massive retroperitoneal emphysema. New Zealand M. 7., 1963, 62, SPERLING, L., and RIGLER, L. G. Traumatic retroperitoneal rupture of duodenum: description of valuable roentgen observation in its recognition. Radiology, 1937, 29,

8 This article has been cited by: 1. Jorge A. Soto, Stephan W. Anderson. Hollow Viscus Perforation [CrossRef] 2. Robert A. Older, Reed P. Rice, Frederick M. Kelvin, William M. Thompson, John L. Weinerth Extraperitoneal Gas Following Nephrectomy: Patterns and Duration. The Journal of Urology 120:1, [CrossRef] 3. John P. Welch Unusual abscesses in perforating colorectal cancer. The American Journal of Surgery 131:3, [CrossRef]