Spontaneous perforation of the colon: CT findings and clinical characteristics Poster No.: C-0724 Congress: ECR 2012 Type: Scientific Exhibit Authors: H. Cho, H. Y. Han, T. J. Chun, I. K. Yu ; Daejon/KR, Daejeon/ 1 1 2 3 1 2 3 KR, Deajeon/KR Keywords: Statistics, Decision analysis, Computer Applications-General, CT, Emergency, Abdomen, Colon, Inflammation, Obstruction / Occlusion DOI: 10.1594/ecr2012/C-0724 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 14
Purpose Spontaneous perforation of the colon is defined as a sudden perforation of the normal colon in the absence of diseases such as tumors, diverticulosis or external injury. It is rare, often misdiagnosed and has a high mortality rate. Peritonitis secondary to large bowel perforation due to colonic cancer or benign colorectal disease still remains a major clinical life-threatening condition associated with high morbidity and mortality. CT findings of spontaneous colon perforation are seldom reported in the literature. In this study, we collected 30 cases of spontaneous colon perforation during 2004 to 2011, and analyzed CT findings and clinical features in order to improve the diagnosis and the understanding of this disease. Methods and Materials We retrospectively reviewed CT images and medical records of 45 cases of nontraumatic colonic perforations with histopathologically proven by surgery from May 2004 to April 2011. Among 45 cases, 15 cases were excluded: 11 cases with perforated colon cancer; 2 case with bowel ischemia by TAE; and 2 case with sigmoid colonic diverticulitis. The rest 30 cases of 29 patients were spontaneous colonic perforations. (one patient had two independent events.) (M : F = 18 : 11, Mean age: 68years, range 39-92years) We focused our attention on Clinical manifestations, Pathologic examination Perforation site CT findings Page 2 of 14
1. Specific findings of colonic perforation - colonic focal wall defects - fecal spillage - extraluminal free air 2. Secondary peritonitis signs - edematous colonic wall thickening - pericolonic fat infiltration - fluid collection - peritoneal thickening with enhancement Results Clinical data 29 patients - M : F = 11 : 18 - mean age : 68 years (range 39~92 years) - Symptoms : a sudden lower abdominal pain in all patients - Past medical history chronic debilitating underlying diseases : 12 patients (41.4%) - such as DM, CRF, CHF, and Liver cirrhosis constipation : 4 patients (13.8%) Past GI tract operation history : 5 patients (17.2%) Pathologic examination Confirmed as non-specific chronic or acute inflammation with colonic wall perforation Page 3 of 14
Accompanying necrosis, acute serositis, diffuse hemorrhage and vascular congestion with abundant neutrophil infiltration in the surrounding colonic mucosa Accompanying stercoral colitis caused by fecal impaction in 3 cases Fig. 1: 1A. Perforation of the bowel wall (HE, x 40) 1B. Ascending colonic wall thining, acute and chronic inflammatory infiltrates with fibrinoid vasculitis, and ischemic change in the whole layer of the ascending colon wall (HE, x 100) References: H. Cho; Daejon, KOREA, Republic of CT findings The most common perforation site: sigmoid colon (60%, 18/30) Other perforation site ascending colon (10%, 3/30) transvere colon (10%, 3/30) descending colon (13.3%, 4/30) colostomy site (6.7%, 2/30) Specific findings of colonic perforation focal colonic wall defects (76.6%, 23/30) fecal spillage (70%, 21/30) extraluminal free air (100%, 30/30) Page 4 of 14
--> All cases had two of them at least. Fig. 2: 2A. 70-year-old woman with spontaneous sigmoid colon perforation. Coronal image of three phase abdominal CT (venous phase) shows large amount of fecal spillage(*) from distal sigmoid colon and continuous sigmoid colonic wall (arrow). 2B. There is sigmoid colonic wall defect (blue arrow) on the next coronal CT scan image. References: H. Cho; Daejon, KOREA, Republic of Fig. 3: 3A. Abdominal CT shows large amount of fecal spillage in pelvic cavity(*). 3B. On the 2.5 cm inferior from Figure 3A, there is focal sigmoid colonic wall defect (blue arrow) and fecal spillage from the defect site(*). There is diffuse edematous colonic wall thickening of sigmoid colon as a secondary sign of peritonitis(white arrows). References: H. Cho; Daejon, KOREA, Republic of Page 5 of 14
Fig. 4: 71-year-old woman with spontaneous colostomy site perforation. Contrast enhanced abdominal CT shows extraluminal fee air(*) and fecal spillage(arrow) from perforation site of colostomy. References: H. Cho; Daejon, KOREA, Republic of Secondary peritonitis signs pericolic fat infiltration (96.7%, 29/30) peritoneal thickening with enhancement (83.3%, 25/30) fluid collection (93.3%, 28/30) edematous colonic wall thickening (46.7%, 14/30) Page 6 of 14
Fig. 5: 72-year-old woman with spontaneous descending colon perforation. On axial image and coronal image of abdominal CT show fluid collection(*) and colonic wall thickening(arrow). There is extraluminal free air(*) as specific finding of colonic perforation. References: H. Cho; Daejon, KOREA, Republic of Fig. 6: 74-year-old man with spontaneous ascending colon perforation with severe fecal impaction(*)due to constipation. On axial image and coronal image of CT show fat infiltration(*), much dilatation of ascending colon up to 9 cm without any obstruction of colon. Some part of colonic wall is very thin(blue arrow). White arrow indicates ileocecal valve which is intact. Terminal ileum is normal. There is extraluminal free air(arrowhead) as specific finding of colonic perforation. References: H. Cho; Daejon, KOREA, Republic of Fig. 7: 7A. 50-year-old man with transverse colon perforation. Plain abdomen erect radiograph shows pneumoperitoneum(*)and air-fluid level without much dilatation Page 7 of 14
of small bowel (arrow). 7B. Contrast enhanced CT shows peritoneal thickening with enhancement(arrows) as the sign of secondary peritonitis. There is linear transverse colonic wall defect(red arrow) with free air just next to colonic wall defect. References: H. Cho; Daejon, KOREA, Republic of CT findings Sigmoid colon (18) Ascending Transverse Descending Colostomy Sum (30) colon (3) colon (3) colon (4) site (2) Colonic focal 66.7% (12) 100% (3) 100% (3) 75% (3) 100% (2) 76.6% (23) 83.3% (15) 33.3% (1) 0% (0) 75% (3) 100% (2) 70.0% (21) 100% (3) 100% (4) 100% (2) 100% (30) wall defects Fecal spillage Extraluminal100% (18) 100% (3) free air Edematous 50% (9) colonic wall thickening 0% (0) 100% (3) 25% (1) 50% (1) 46.7% (14) Pericolic 94.4% (17) 100% (3) 100% (3) 100% (4) 100% (2) 96.7% (29) Fluid collection 94.4% (17) 66.7% (2) 100% (3) 100% (4) 100% (2) 93.3% (28) Peritoneal thickening with 88.9% (16) 66.7% (2) 66.7% (2) 100% (4) 50% (1) 83.3% (25) fat infiltration enhancement Prognosis Three patients died after surgery (10.3%, 3/29). 1) Two patients died within 3 days after surgery. - One had two spontaneous colonic perforation. --> In 2nd operation, there was colostomy necrosis Page 8 of 14
and perfortation due to fecal impaction. - One had bowel ischemia. 2) One patient died one month after surgery. - The patient had peritonitis due to small bowel, sigmoid colon and descending colon necrosis one month after colon perforation. - She had 2nd operation of total colectomy, small bowel resection and anastomosis, loop ileostomy and segmental resection of sigmoid colon. - Three days after 2nd surgery, she had another operation due to peritonitis caused by ileostomy site perforation. Images for this section: Page 9 of 14
Fig. 1: 1A. Perforation of the bowel wall (HE, x 40) 1B. Ascending colonic wall thining, acute and chronic inflammatory infiltrates with fibrinoid vasculitis, and ischemic change in the whole layer of the ascending colon wall (HE, x 100) Fig. 2: 2A. 70-year-old woman with spontaneous sigmoid colon perforation. Coronal image of three phase abdominal CT (venous phase) shows large amount of fecal spillage(*) from distal sigmoid colon and continuous sigmoid colonic wall (arrow). 2B. There is sigmoid colonic wall defect (blue arrow) on the next coronal CT scan image. Fig. 3: 3A. Abdominal CT shows large amount of fecal spillage in pelvic cavity(*). 3B. On the 2.5 cm inferior from Figure 3A, there is focal sigmoid colonic wall defect (blue arrow) and fecal spillage from the defect site(*). There is diffuse edematous colonic wall thickening of sigmoid colon as a secondary sign of peritonitis(white arrows). Page 10 of 14
Fig. 4: 71-year-old woman with spontaneous colostomy site perforation. Contrast enhanced abdominal CT shows extraluminal fee air(*) and fecal spillage(arrow) from perforation site of colostomy. Fig. 5: 72-year-old woman with spontaneous descending colon perforation. On axial image and coronal image of abdominal CT show fluid collection(*) and colonic wall thickening(arrow). There is extraluminal free air(*) as specific finding of colonic perforation. Page 11 of 14
Fig. 6: 74-year-old man with spontaneous ascending colon perforation with severe fecal impaction(*)due to constipation. On axial image and coronal image of CT show fat infiltration(*), much dilatation of ascending colon up to 9 cm without any obstruction of colon. Some part of colonic wall is very thin(blue arrow). White arrow indicates ileocecal valve which is intact. Terminal ileum is normal. There is extraluminal free air(arrowhead) as specific finding of colonic perforation. Fig. 7: 7A. 50-year-old man with transverse colon perforation. Plain abdomen erect radiograph shows pneumoperitoneum(*)and air-fluid level without much dilatation of small bowel (arrow). 7B. Contrast enhanced CT shows peritoneal thickening with enhancement(arrows) as the sign of secondary peritonitis. There is linear transverse colonic wall defect(red arrow) with free air just next to colonic wall defect. Page 12 of 14
Conclusion 1. All patient had extraluminal free-air and either focal colonic wall defects or fecal spillage. 2. Sigmoid colon is the most frequent site of the spontaneous colonic perforation. due to the special physiological and anatomical features of sigmoid colon - no ramus anastomoticus between the lowest branch of sigmoid arteries and the superior rectal artery --> a physiological ischemia 3. Patients are more fetal having necrosis(bowel ischemia) in pathology. 4. Poor vascular supply and fecal impaction can be suggested main cause of spontaneous colon perforation. Constipation --> fecal impaction DM, CRF, CHF, Liver cirrhosis --> poor vascularity Elder patients Spontaneous perforation of the colon most commonly occurs to the elderly with chronic debilitating underlying diseases, so the mortality and morbidity rate after surgery are high. Sigmoid colon is the most frequent site of the spontaneous colonic perforation, and characteristically colonic wall defects, massive fecal spillage and extraluminal free air are observed on CT scans. References 1. Zhang MJ, Wu JB. Treatment of spontaneous perforation of the large intestine: a report of 9 cases. Zhongguo Putong Waike Zazhi 2002; 32: 836-8392. 2. Runkel NS, Schlag P, Schwarz V, Herfarth C. Outcome after emergency surgery for cancer of the large intestine. Br J Surg 1991; 78:183-1883. Page 13 of 14
3. Krivanek S, Armbruster C, Dittrich K, Beckerhinn P. Perforated colorectal cancer. Dis Colon Rectum 1996; 39:1409-14144. 4. Nespoli A, Ravizzini C, Trivella M, Segala M. The choice of surgical procedure for peritonitis due to colonic perforation. Arch Surg 1993; 128:814-8185. 5. Bo Yang, Huai-Kun Ni Diagnosis and treatment of spontaneous colonic perforation: Analysis of 10 cases World J Gastroenterol 2008 July 28; 14(28): 4569-45726. 6. WS Huang, CS Wang, CC Hsieh, PY. Lin Management of patients with stercoral perforation of the sigmoid colon: report of five cases. World J Gastroenterol 2006; 12: 500-5037. 7. Matsuo S, Eguchi S, Azuma T, Kanetaka K, Itoh S, Yamaguchi S, Obata S, Kanematsu T. An unusual perforation of the colon: report of two cases. Surg Today 2002; 32: 836-8398. 8. Hao WX. Analysis of the etiology and treatment for 18 cases with colonic perforation. Henan Waikexue Zazhi 2004; 10: 46-479. 9. Wang ZQ. Analysis of diagnosis and treatment of spontaneous enterorrhexis. Xinjiang Yixue 2006; 4: 58-5910. 10. Zhang LX, Mao GJ, Shao AP. Diagnosis and treatment of spontaneous colonic perforation for 16 cases. Zhonghua Weichang Waike Zazhi 2006; 9: 249 Personal Information Page 14 of 14