Intraperitoneal Barium From Gastrointestinal Perforations: Reassessment of the Prognosis and Long-Term Effects.

OBJECTIVE. The purpose of this study was to reassess the outcome and potential consequences of intraperitoneal barium leakage during radiologic evaluation of the gastrointestinal tract. MATERIALS AND METHODS. This retrospective study included 18 patients who had significant intraperitoneal leakage of barium from gastrointestinal perforations that were not suspected or diagnosed before the radiologic procedures. This complication occurred during a barium enema examination in nine patients, an upper gastrointestinal study in seven, and a small bowel series in two patients. All patients underwent urgent laparotomy for repair of perforation, with vigorous peritoneal lavage and antibiotic therapy. RESULTS. All patients had an uneventful recovery and were followed for 4-17 years (mean, 8.5 years). Radiographs obtained during this interval showed that a significant amount of residual barium was retained in the abdominal cavity. Six patients had a total of 10 subsequent abdominal operations for unrelated conditions, and some had developed barium granulomas and peritoneal adhesions. However, none of the patients in this series experienced intestinal obstruction or any clinical symptoms related to barium deposits in the abdominal cavity. CONCLUSION. Intraperitoneal leakage of barium is a rare complication of radiologic gastrointestinal examinations, and this series of 18 cases reflects 3 decades of experience at two major medical centers. The presented data indicate that the commonly held and perpetuated concept about the high rate of morbidity and mortality of this complication would not be valid in the modern era of medical and surgical management.

Diagnostic effectiveness of preoperative water-soluble contrast enema in colorectal perforation.

OBJECTIVE: To evaluate the diagnostic usefulness of performing a preoperative water-soluble contrast enema (WSCE) before emergency surgery for colorectal perforation. METHODS: We retrospectively reviewed 68 consecutive patients who underwent a preoperative WSCE before emergency surgery for colorectal perforation during the period from January 2011 to December 2017. Clinical characteristics and inflammatory biomarkers were compared between patients with Hinchey I-II versus those with Hinchey III-IV. RESULTS: WSCE leakage occurred in 27 of 68 patients (39.7%). Univariate analysis showed that the two groups (Hinchey I-II and Hinchey III-IV) significantly differed regarding age, perforation site, cause of perforation, American Society of Anesthesiologists grade, presence or absence of WSCE leakage, and white blood cell count. Multivariable analysis revealed that WSCE leakage was a predictor of Hinchey III-IV, with an odds ratio of greater than 24 (P = 0.002). The sensitivity and specificity of WSCE leakage for differentiating those with Hinchey III-IV from those with Hinchey I-II were 76.5% and 97.1%, respectively. CONCLUSIONS: This retrospective study indicates that preoperative WSCE before emergency surgery is a useful tool for predicting the presence of Hinchey III-IV in patients with colorectal perforation.

Role of Multidetector Computed Tomography in the Diagnosis of Colorectal Perforations.

Colonic perforations can be classified into perforations that occur at the site of a localized pathologic process and cecal perforations that occur secondary to distal colonic obstructions. Rectal perforations may result from foreign bodies inserted into the rectum; moreover, deep rectal biopsies, polypectomy, improper cleansing enema, or thermometer placement may also lead to rectal perforation. Correct identification of the cause and site of the perforation is crucial for appropriate management and surgical planning. Multidetector row computed tomography has a pivot role in planning the type of operative treatment, the prognosis, and in assessing those patients who have clinical symptoms of peritonitis but no radiographic signs of perforation.

Ogilvie's syndrome-related right colon perforation after cesarean section: a case series.

The objective of this article is to discuss and report three cases of right colon perforation secondary to postcesarean Ogilvie's syndrome (OS; colonic pseudo-obstruction) requiring right hemicolectomy. We retrospectively reviewed the case notes of three patients who underwent caesarean section and postoperatively developed OS. OS is an uncommon problem in patients undergoing caesarean section. Abdominal X-ray and water-soluble contrast enema are the main diagnostic modalities. Drip-suck therapy along with endoscopic or pharmacological decompression should be performed in early stages. In a significant percentage of patients, diagnosis is delayed resulting in bowel ischemia and perforation requiring surgical resection and adding significant mortality/morbidity. We recommend our obstetric colleagues to involve surgical team in earlier stages to avoid surgery-related mortality and morbidity. We also advocate general surgeons to be aware of OS in patients after caesarean section and recommend a stepwise systematic approach toward the diagnosis and management of OS.

Chronic colonic perforation in pseudomyxoma peritonei.

Pseudomyxoma peritonei (PP) produces abundant mucoid material from the rupture of low grade ovarian or appendiceal mucinous tumours. The unique pattern of cancer dissemination and intraperitoneal mucous re-distribution makes it a distinct clinical condition. It has diverse presentations, mainly as a result of narrowing of the gastrointestinal tract and entrapment of other viscera by gelatinous mucoid material. Imaging is helpful, but not diagnostic of this condition. We report a patient with pseudomyxoma perotonei who had perforation at the recto-sigmoid junction into a large mucinous cyst adjacent to the sigmoid colon. The patient improved clinically with conservative management, with persisting communication and no adverse symptoms reported at 4 months follow-up.

Gastrointestinal tract perforation: CT diagnosis of presence, site, and cause.

Gastrointestinal tract perforation is an emergent condition that requires prompt surgery. Diagnosis largely depends on imaging examinations, and correct diagnosis of the presence, level, and cause of perforation is essential for appropriate management and surgical planning. Plain radiography remains the first imaging study and may be followed by intraluminal contrast examination; however, the high clinical efficacy of computed tomographic examination in this field has been well recognized. The advent of spiral and multidetector-row computed tomographic scanners has enabled examination of the entire abdomen in a single breath-hold by using thin-slice sections that allow precise assessment of pathology in the alimentary tract. Extraluminal air that is too small to be detected by conventional radiography can be demonstrated by computed tomography. Indirect findings of bowel perforation such as phlegmon, abscess, peritoneal fluid, or an extraluminal foreign body can also be demonstrated. Gastrointestinal mural pathology and associated adjacent inflammation are precisely assessed with thin-section images and multiplanar reformations that aid in the assessment of the site and cause of perforation.

Computed tomography evaluation of diverticulitis.

Acute diverticulitis is a frequent and important diagnosis in gastrointestinal disease, most commonly involving the colon. It is estimated that approximately 15% to 30% of patients with diverticulosis develop symptomatic diverticulitis at some point in the natural history of the condition, often requiring medical and/or surgical therapy. The clinical diagnosis is often difficult to make, and several radiological studies have been used over the past decades to assist in the diagnosis of acute diverticulitis. These include barium enema, ultrasound, and computed tomography (CT). A number of studies over the past decade have shown CT to be the preferable initial examination because of its ability to demonstrate not only the extent of intramural inflammation but also the degree of pericolic disease, including intraperitoneal inflammation, perforation, and abscess formation. Additional benefits of CT imaging include guiding therapeutic interventions in complicated forms of diverticular disease and providing an alternative diagnosis in patients without diverticulitis. The accuracy, techniques, criteria for diagnosis, and staging and applications of CT imaging in acute diverticulitis are discussed.

Perforations of the rectosigmoid colon induced by cleansing enema: CT findings in 14 patients.

BACKGROUND: We report the computed tomographic (CT) features of colorectal perforations caused by cleansing enema. METHODS: We reviewed the medical records and CT studies of all patients with colorectal perforations caused by a cleansing enema. RESULTS: Fourteen patients (10 men, four women; average age = 80 years) were included in the study. The most common presenting symptoms were severe abdominal pain and fever. CT was performed within 48 h after the event in most patients. Extraluminal air in the perirectal fat was the most frequent finding on CT and was present in all patients. Additional findings were extraperitoneal ( n = 9), intraperitoneal ( n = 3) and /or subcutaneous ( n = 3) air, free fluid ( n = 9), extraluminal feces ( n = 8), and focal bowel wall thickening ( n = 4). No leak of contrast from the rectum was observed in any patient including the one patient in whom contrast was administered rectally. Ten patients were treated by surgery; five recovered and the other five died. The other four patients were treated conservatively and all four died. CONCLUSION: The diagnosis of colorectal perforation can be made on CT. Because the diagnosis is not always suspected by the clinician, the radiologist may be the first to suggest it. Therefore, the radiologist should be familiar with the CT features of a potentially lethal, rectally induced perforation.

[Septic shock caused by perforation of sigmoid diverticulum into the Retzius space. A case report]. / Shock settico da perforazione di un diverticolo del sigma nello spazio del Retzius. Descrizione di un caso clinico.

An uncommon complication of the sigmoid diverticulitis personally observed is described. A woman, 59 years old, presented a septic shock caused by perforated sigmoid diverticulum into the space of Retzius. The diagnosis was carried out by an X-ray of the abdomen that suspected the presence of air in the retroperitoneum and then by barium enema showing a perforation of the sigmoid colon. During laparotomy a perforation of sigmoid diverticulum in to the space of Retzius was observed. So the space of Retzius was opened and then pus and watery exudate containing bubbles of gas were found extended also to the retroperitoneum and the right abdomen wall. The patient was submitted to a sigmoid resection; bowel continuity was restored by circular stapled anastomosis and a temporary colostomy was made. Some drainages were placed into the space of Retzius, into the retroperitoneum and into the peritoneal cavity. Nevertheless the patient died because of the septic shock and the postoperative MOF.

Meckel's diverticulum mimicking infantile colic: sonographic detection.

We report a case of Meckel's diverticulum in a 6-month-old girl who presented with a 5-month history of chronic screaming but no symptoms or signs of intestinal obstruction. Infantile colic was the presumptive diagnosis. Abdominal sonography at 6 months of age demonstrated an abdominal mass with an anechoic center and a double-layered wall, surrounded by bowel loops. Abdominal CT and barium enema x-ray studies demonstrated nonspecific findings of a cystic mass with compression of adjacent bowel loops. Histologic examination of the resected mass revealed a Meckel's diverticulum with a perforation sealed off by the neighboring bowel and mesentery to form an inflammatory mass.

Malignant peritoneal mesothelioma with mimicry of pseudomyxoma peritonei in a patient with a history of perforated sigmadiverticulitis.

We describe a 57-year-old man who presented with diffuse abdominal pain, abdominal enlargement, vomitus, dyspnea and a weight loss of 30 kg within 6 months. These acute symptoms were preceded by an episode of ascites and an acute sigmadiverticulitis 7 months ago. Ultrasonography and computed tomography were suggestive of pseudomyxoma peritonei. However, malignant mesothelioma peritonei was diagnosed by open surgery with biopsy for histological examination. Despite R-2-resection of the tumor and following open hyperthermic intraperitoneal chemotherapy with initial remarkable recovery the patient died 5 months after therapeutical intervention. Malignant peritoneal mesothelioma is an extremely rare tumor with great diagnostic and therapeutic difficulties. We report a case including diagnostical work up and the medical surgical therapy of this disease.

Enema-induced perforation of the rectum in chronically constipated patients.

INTRODUCTION: The use of retrograde irrigation enemas is common in the treatment of chronic constipation, especially in the elderly. Perforation of the rectum and sigmoid colon caused by cleansing enemas, used by chronically constipated patients, has not been previously described. METHODS: We reviewed all patients with colorectal perforations caused by irrigation enemas admitted to our service in the three-year period between January 1995 and December 1997. RESULTS: Thirteen patients were treated by our surgical service because of perforations of the rectum and sigmoid colon related to a previous retrograde irrigation enema. Ten of these patients came from nursing homes, and the other three lived at home. The relevant information relating the enema administration to the patient's condition was given in only two of the ten patients referred to the emergency room by the institution's nursing or medical staff. In the other eight the information was vague and sometimes misleading. The diagnosis of colorectal perforation was made by history, plain abdominal x-rays, and CT scan with or without meglumine diatrizoate enemas. Ten patients survived, regardless of age, previous diseases, or operative findings. In all of them, diagnosis was made within 36 hours from the perforation. The three deaths occurred in patients in whom the diagnosis was made late. CONCLUSIONS: Awareness of the possible injury from enemas administered to chronically constipated patients should be stressed. A high degree of suspicion by the attending physician is extremely important, because prompt diagnosis and early surgical treatment carries a relatively good prognosis.

Tension fecopneumothorax due to colonic perforation in a diaphragmatic hernia.

A traumatic diaphragmatic hernia is a well-known complication following blunt abdominal or penetrating thoracic trauma. Although the majority of cases are diagnosed immediately, some patients may present later with a diaphragmatic hernia. A tension fecopneumothorax, however, is a rarity. We report on a patient who, 2 years after being treated for a stab wound to the chest, presented with an acute tension fecopneumothorax caused by the incarceration of the large bowel in the thoracic cavity after an intrathoracic perforation. The etiology and management of this condition are discussed.