Complicated Meckel's Diverticulum Presenting as Pneumoperitoneum in an Adolescent.

BACKGROUND The finding of pneumoperitoneum frequently leads to operative management for diagnosis and treatment. The etiology of pneumoperitoneum includes perforated viscus, such as perforated peptic ulcers, small or large intestinal perforations, appendicitis, and complicated sigmoid diverticulitis. We describe the preoperative, intraoperative, and postoperative course of a patient with perforated Meckel’s diverticulitis presenting with pneumoperitoneum. This unusual presenting finding highlights that Meckel’s diverticulum should be included in the differential diagnosis in adolescents and young adults presenting with pneumoperitoneum. CASE REPORT We describe a case of an 18-year-old male who presented with 1 day of abdominal pain, found to have pneumoperitoneum during workup, attributed to perforated Meckel’s diverticulum. CT scans of the abdomen and pelvis were performed, confirming pneumoperitoneum, an inflamed segment of distal ileum, and a non-visualized appendix, which made the diagnosis difficult. Perforated Meckel’s diverticulum, likely due to infection, was confirmed by diagnostic laparoscopy. The Meckel’s diverticulum was then exteriorized and removed by segmental small bowel resection with primary anastomosis. The final pathology report confirmed perforated Meckel’s diverticulum with gastric oxyntic-type mucosa. CONCLUSIONS This case illustrates an uncommon presentation of Meckel’s diverticulum in an adolescent with pneumoperitoneum. Pneumoperitoneum requires broadening the diagnosis to include other causes, including Meckel’s diverticulum, especially in the setting of an acute abdomen. This case highlights that a high index of suspicion should be kept for Meckel’s diverticulum, even in adolescents and young adults with pneumoperitoneum.

Intestinal Perforation in a Case of Peripheral T Cell Lymphoma after Initiation of Chemotherapy.

Non-Hodgkin's lymphoma (NHL) is the most common type of Gastrointestinal (GI) lymphoma with known complications such as bleeding, obstruction and perforation. In this article we present a 59-year-old male patient diagnosed with Peripheral T cell Lymphoma - Not Otherwise Specified (PTCL-NOS) with GI involvement was started on chemotherapy. On day 2 post completion of first cycle of chemotherapy, patient had presented to the emergency department with sudden onset abdominal pain and distension. On evaluation, he was diagnosed with multiple perforations in the small bowel. Patient underwent exploration with primary repair of few perforations and ileal resection with double barrel ileostomy. Chemotherapy plays an important role in the management of NHL. One well-known NHL consequence, intestinal perforation, can happen at the time of initial presentation or after starting chemotherapy. Surgeons should be aware of possibility of such complications and high-risk factors for perforation. At present, there is no role for elective surgery in GI lymphoma and is mainly reserved for complications like uncontrolled bleeding, obstruction or perforation.

Polyarteritis nodosa complicated by renal aneurysm and intestinal perforation: A case report.

RATIONALE: Polyarteritis nodosa (PAN) is a necrotizing vasculitis that affects small- and medium-sized arteries, presenting with diverse clinical manifestations. It can impact tissues and organs throughout the body and may be life-threatening in severe cases. Common causes of death include cardiac, renal, and gastrointestinal complications or aneurysm rupture. While separate reports of renal aneurysm and intestinal perforation exist, the coexistence of these conditions is rarely documented. This study reports a severe case of PAN complicated by both renal aneurysm and intestinal perforation, aiming to deepen the understanding of this disease, aid in clinical diagnosis and treatment, and improve patient prognosis. PATIENT CONCERNS: The patient presented to the hospital with dorsal foot pain and abdominal pain persisting for more than 4 months, along with pain and discomfort in both lower extremities for over 1 month. INTERVENTIONS: The patient was diagnosed with PAN, renal aneurysm, intestinal perforation, and grade 3 hypertension (high risk). OUTCOMES: After treatment, the patient showed normal temperature and blood pressure, relief from abdominal pain, and disappearance of myalgia and numbness in the lower limbs. Additionally, the renal aneurysm shrank significantly, the intestinal perforation healed, the ileostomy was reduced, and the patient's condition stabilized. LESSONS: The clinical symptoms of PAN mostly lack specificity, and should be distinguished from microscopic polyangiitis and simulated vasculitis. For patients with intestinal perforation similar to this case, tocilizumab treatment may be effective, but further research is needed to confirm it.

Clinical Predictors of Spontaneous Intestinal Perforation vs Necrotizing Enterocolitis in Extremely and Very Low Birth Weight Neonates.

PURPOSE: Spontaneous intestinal perforation (SIP) and necrotizing enterocolitis (NEC) are distinct disease processes associated with significant morbidity and mortality. Initial treatment, laparotomy (LP) versus peritoneal drainage (PD), is disease specific however it can be difficult to distinguish these diagnoses preoperatively. We investigated clinical characteristics associated with each diagnosis and constructed a scoring algorithm for accurate preoperative diagnosis. METHODS: A cohort of extreme and very low birth weight (<1500 g) neonates surgically treated for SIP or NEC between 07/2004-09/2022 were reviewed. Clinical characteristics included gestational age (GA), birth weight (BW), feeding history, physical exam, and laboratory/radiological findings. Intraoperative diagnosis was used to determine SIP vs NEC. Pre-drain diagnosis was used for patients treated with PD only. RESULTS: 338 neonates were managed for SIP (n = 269, 79.6%) vs NEC (n = 69, 20.4%). PD was definitive treatment in 146 (43.2%) patients and 75 (22.2%) patients were treated with upfront LP. Characteristics associated with SIP included younger GA, younger age at initial laparotomy or drainage (ALD), and history of trophic or no feeds. Multivariate logistic regression determined pneumatosis, abdominal wall erythema, higher ALD and history of feeds to be highly predictive of NEC. A 0-8-point scale was designed based on these characteristics with the area under the receiver operating characteristic curve of 0.819 (95% CI 0.756-0.882) for the diagnosis of NEC. A threshold score of 1.5 had a 95.2% specificity for NEC. CONCLUSION: Utilizing clinical characteristics associated with SIP & NEC we developed a scoring system designed to assist surgeons accurately distinguish SIP vs NEC in neonates. TYPE OF STUDY: Retrospective Chart Review. LEVEL OF EVIDENCE: Level III.

Perforation of Jejunal Metastasis from Primary Lung Carcinoma with Brain Metastasis: A Rare Case.

A case describes a 49-year-old male patient who underwent emergency exploratory laparotomy for small intestinal perforation. Peritonitis was present due to perforation of the jejunal tumor. Resection of the jejunal tumor with perforation was performed followed by end-to-end anastomosis of the jejunum. The resected jejunal tumor was identified in the histopathological examination as metastatic from a clear cell variant of squamous cell/large cell carcinoma of the lung. It was associated with metastatic lesions in the brain. Metastasis from the lung carcinoma in the jejunum is a very rare condition predisposing to small intestinal perforation which is also associated with brain metastasis.

[Beware of labels]. / 5 minutes pour apprendre. Gare aux étiquettes.

A 50-year-old individual identified as a 'frequent user' of emergency services due to chronic abdominal pain was transported to the emergency department by ambulance during a new episode of abdominal pain. Despite being initially deemed stable by paramedics, the patient was not reassessed by the triage nurse upon arrival. Subsequently, the patient presented with severe pain, arterial hypotension, and tachycardia. Following a multidisciplinary protocol for pain management, analgesic treatment was initiated. Despite several hours of management and repeated assessments, an abdominal CT-scan was eventually conducted, revealing a perforated small intestine. The application of the 'frequent user' label may have contributed to a delay in the provision of timely care for this patient.

Unintentional Plastic Blister Ingestion Leading to Intestinal Perforation: A Report of Two Cases.

BACKGROUND Unintentional medication-blister ingestion is rare but frequently leads to intestinal perforation. The diagnosis of intestinal perforation following blister ingestion is often delayed because of an unreliable history and nonspecific clinical presentation. The purpose of this case report is to raise awareness about a rare but difficult diagnosis and its importance in avoiding potentially fatal events. CASE REPORT Herein, we describe successful cases of surgical and endoscopic removal after blister ingestion. The first case was that of a polymorbid 75-year-old man who presented with acute onset of abdominal pain in the right upper quadrant and epigastric regions. No indication of the cause was observed on initial computed tomography (CT). The patient developed an acute abdomen, and emergency laparotomy was performed, during which 2 small perforations were observed in the terminal ileum, and an empty tablet blister was retrieved. The second patient was a 55-year-old man who presented with a considerable lack of awareness. On the initial CT, a subdural hematoma, aspiration, and an unidentified foreign body in the stomach were observed. Gastroscopy was performed after emergency craniotomy. In addition to the initial foreign body, a second object, which had gone unnoticed on the initial CT, was found and removed from the esophagus. CONCLUSIONS With an increased risk of perforation and difficult clinical and radiological diagnoses, prophylactic measures and special awareness of high-risk patients are particularly important.

Colorectal Oncologic Emergencies: Recognition, Management, and Outcomes.

Colorectal cancer is the third most frequent type of malignancy in the United States, and the age at diagnosis is decreasing. Although the goal of screening is focused on prevention and early detection, a subset of patients inevitably presents as oncologic emergencies. Approximately 15% of patients with colorectal cancer will present as surgical emergencies, with the majority being due to either colonic perforation or obstruction. Patients presenting with colorectal emergencies are a challenging cohort, as they often present at an advanced stage with an increase in T stage, lymphovascular invasion, and metachronous liver disease.

IgG4-related disease complicated with diffuse and chronic gastrointestinal inflammation leading to small intestinal perforation.

Immunoglobulin (Ig) G4-related disease (IgG4-RD) is a systemic inflammatory disease characterised by elevated serum IgG4, IgG4+ cell infiltration, storiform fibrosis, and obliterative phlebitis. While IgG4-RD can affect various organs, gastrointestinal tract involvement is less common. Here, we report a 70-year-old female with IgG4-RD complicated with diffuse and chronic gastrointestinal inflammation, which led to small intestinal perforation. She had been suffering from anorexia, abdominal pain, vomiting, and diarrhoea and hospitalised due to recurrent ileus. Consequently, she was referred due to small intestinal perforation required for surgical intervention. Pathology revealed acute and chronic inflammation with massive IgG4+ plasmacyte infiltration into mucosa of the small intestine and ischaemic change secondarily caused by chronic inflammation. Random biopsies from the mucosa of stomach, duodenum, ileum, and colon also revealed diffuse and massive IgG4+ plasmacyte infiltration in stomach, duodenum, small intestine, and colon. She was diagnosed with IgG4-RD based on the pathological findings and elevated serum IgG4 levels. Glucocorticoid rapidly ameliorated the symptoms. IgG4-RD may cause gastrointestinal manifestations, and histopathological assessment should be considered, even in the absence of specific characteristics of IgG4-RD.

Mucormycosis presenting as intestinal perforation: A pathologist perspective.

Mucormycosis is a life-threatening fungal infection mostly involving the ocular region, sinuses and brain. It is mostly seen in the immunocompromised host. Gastrointestinal (GI) mucormycosis is rare and mostly present as hematemesis, abdominal pain and melena. Here, we present a case of intestinal mucormycosis who presented as cecal perforation. Surgical resection was done, and the diagnosis was made by histopathology. Our case is unique in the way that GI mucormycosis is itself a rare entity and even rarer in an immunocompetent host.

Outcomes for pediatric acute lymphoblastic leukemia patients with intestinal perforation.

OBJECTIVES: Intestinal perforation during acute lymphoblastic leukemia (ALL) treatment in children is rare, but represents a severe complication with possible long-term consequences. In this study, we aim to provide an overview of the epidemiology and clinical characteristics of these patients; analyze surgical pathology findings for possible causes; and determine its impact on patients' therapy, nutritional status, and outcome. STUDY DESIGN: Historical chart review from January 2000 to October 2020 of children with ALL and intestinal perforation during therapy diagnosed at a single institution. Data collected included patient demographics, anthropometric measurements, ALL characteristics, diagnosis and surgery of intestinal perforation, pathology, adjustments to treatment plan, and outcome. RESULTS: Of 1840 ALL patients, 13 (0.7%) presented with intestinal perforation during treatment. Perforation occurred during induction phase in 91% of cases. Most patients underwent laparotomy with ostomy creation, and no patient died from the intervention or developed malnutrition. Pathology mainly revealed inflammation at the perforation site. Two samples showed leukemic infiltration and presence of microorganisms. Patients were able to resume ALL therapy in all cases. A total of eight patients (73%) were in first remission at last follow-up, with a median follow-up time of 42 months (interquartile range = 42). CONCLUSION: Early surgical intervention is a successful treatment approach for intestinal perforation in ALL patients. There is a clear predilection for induction phase in the occurrence of intestinal perforation in ALL patients. No specific cause was identified. Patients can receive bridging chemotherapy during surgical recovery and proceed with their treatment without apparent impact on outcome.

Jejunal perforation and septic abdomen resulting from a choristoma in a dog.

A 4.6-year-old spayed female German shepherd dog was admitted to a specialty hospital emergency service upon referral for suspected gastrointestinal foreign body obstruction. Free abdominal fluid was collected, and results of cytologic evaluation were consistent with a septic abdomen. An abdominal barium study revealed free gas and intraperitoneal barium, along with an obstructive gas pattern within the small bowel. Ultrasonography revealed a full-thickness jejunal perforation. On exploratory laparotomy, the perforation was noted to be located mid-jejunum with no associated mass or foreign material. A resection and anastomosis were completed. Histopathologic evaluation of the affected jejunal tissue showed aberrant gastric glandular epithelium consistent with a gastric choristoma, or heterotopic gastric tissue. Key clinical message: Clinicians should consider gastric glandular choristoma as a differential diagnosis in cases of seemingly idiopathic small intestinal perforation with no known cause (i.e., foreign body penetration, neoplasia, NSAID use), and histopathologic evaluation should always be done to obtain a definitive diagnosis.

Perforation jéjunale et abdomen septique résultant d'un choristome chez un chien. Une chienne berger allemand stérilisée âgée de 4,6 ans a été admise dans le service d'urgence d'un hôpital spécialisé après avoir été référée pour une suspicion d'obstruction gastro-intestinale par un corps étranger. Du liquide abdominal libre a été prélevé et les résultats de l'évaluation cytologique étaient compatibles avec un abdomen septique. Un examen abdominal à l'aide de baryum a révélé du gaz libre et du baryum intrapéritonéal, ainsi qu'un patron de gaz obstructif dans l'intestin grêle. L'échographie a révélé une perforation sur toute l'épaisseur jéjunale. Lors d'une laparotomie exploratoire, il a été constaté que la perforation était située au milieu du jéjunum, sans masse ni corps étranger associé. Une résection et une anastomose ont été réalisées. L'évaluation histopathologique du tissu jéjunal affecté a montré un épithélium glandulaire gastrique aberrant compatible avec un choristome gastrique ou un tissu gastrique hétérotopique.Message clinique clé :Les cliniciens doivent considérer le choristome glandulaire gastrique comme diagnostic différentiel dans les cas de perforation de l'intestin grêle apparemment idiopathique sans cause connue (i.e. pénétration d'un corps étranger, néoplasie, utilisation d'AINS), et une évaluation histopathologique doit toujours être effectuée pour obtenir un diagnostic définitif.(Traduit par Dr Serge Messier).

Comparison of preoperative and intraoperative surgeon diagnosis and pathologic findings in spontaneous intestinal perforation vs necrotizing enterocolitis.

OBJECTIVE: To investigate the accuracy of preoperative and intraoperative diagnosis via comparison to pathologic diagnosis in spontaneous intestinal perforation (SIP) vs. necrotizing enterocolitis (NEC). STUDY DESIGN: A retrospective review of neonates <1500 g treated for pneumoperitoneum between 07/2004-09/2022 was conducted. Patients treated for NEC medically prior to diagnosis and those treated with drain only were excluded. Fleiss' Kappa analysis assessed agreement between all three diagnoses: preoperative, intraoperative, and pathologic. RESULT: Overall, 125 patients were included with mean birthweight 834.2 g (SD:259.2) and mean gestational age 25.8 weeks (SD:2.2). Preoperative and intraoperative diagnoses agreed in 90.3%, intraoperative and pathologic agreed in 71.1%, and preoperative and pathologic agreed in 75.2% of patients. Fleiss' Kappa was 0.55 (95% CI:0.43,0.68), indicating moderate agreement between the three diagnoses. CONCLUSION: Our study shows moderate agreement between preoperative, intraoperative, and pathologic diagnoses. Further studies investigating the clinical characteristics of SIP and NEC are needed to improve diagnostic accuracy and management.

Gastrointestinal perforation associated with bevacizumab in metastatic colorectal cancer.

OBJECTIVE: To investigate the risk factors for gastrointestinal perforation in metastatic colorectal cancer patients receiving bevacizumab. METHODS: We retrospectively reviewed 217 patients with metastatic colorectal cancer receiving bevacizumab to investigate the risk factors for gastrointestinal perforation. Three patients occurred intestinal perforation after receiving bevacizumab. We analyzed the clinical characteristics of three patients with intestinal perforation. RESULTS: All patients receiving bevacizumab. Three of 217 patients occurred intestinal perforation after receiving bevacizumab. Patient no. 1 was 70 years old, female, having history of intestinal obstruction. The patient occurred intestinal perforation and ultimately died after receiving bevacizumab. Patient no. 2 was 59 years old, female, having history of intestinal obstruction. The patient occurred intestinal perforation after receiving bevacizumab, and recovered smoothly after symptomatic treatment. Patient no. 3 was 60 years old, female, having history of intestinal obstruction. The patient occurred intestinal perforation and ultimately died after receiving bevacizumab. CONCLUSIONS: Patients with advanced colorectal cancer receiving bevacizumab are at risk of gastrointestinal perforation. The patient's age, gender and history of bowel obstruction may be associated with gastrointestinal perforation.

Acute abdominal perforation as a clinical presentation of coeliac disease.

Intestinal perforation is described in coeliac disease in the setting of refractoriness or Enteropathy-Associated T-cell Lymphoma (EATL). We report the case of a man with untreated coeliac disease who presented intestinal perforation and was diagnosed with EATL over one year later.

[Surgical treatment of a patient with tubular colonic duplication complicated by perforation and peritonitis]. / Uspeshnoe lechenie patsienta s tubulyarnoi duplikatsiei tolstoi kishki, oslozhnennoi perforatsiei i peritonitom.

We present successful treatment of a patient with tubular colonic duplication complicated by fecal impaction, perforation and fecal peritonitis. This anomaly is usually detected in children younger 2 years old. In adulthood, this diagnosis is of a precedent-setting nature. If the diagnosis was not confirmed in early childhood, the absence of typical clinical picture, long-term course of disease and difficult interpretation of clinical data complicate subsequent verification of congenital anomaly. Only infectious complications and emergency surgery in adults can make a correct diagnosis.

Spontaneous rectosigmoid perforation at the watershed area of the Sudeck point in an apparently healthy toddler boy: a case report.

BACKGROUND: Spontaneous colon perforation can be classified into stercoral and idiopathic. Stercoral type is associated with chronic constipation, thus it is rare in infants and children. The idiopathic type is sporadic and could occur at any age. Delay in diagnosing or treating idiopathic colon perforation is associated with high mortality and morbidity rates. There are few studies on rectal perforation related to other etiologies or past the neonatal period, and their effect on disease onset and prognosis are unknown. CASE PRESENTATION: We report on a case of 2-year-and-5-month-old Oromo boy who presented with fever, diarrhea, vomiting, and progressive abdominal pain of 5-day duration. The boy underwent an exploratory laparotomy for suspected peritonitis and there was a single perforation of approximately 2.0 cm size in the anterior part of the upper one-third of rectum. The perforated rectum was repaired primarily and sigmoid divided diversion colostomy was carried out. CONCLUSION: It is important to be aware of idiopathic colon perforation in children, a rare but dangerous condition with high mortality and morbidity in cases of delayed diagnosis or management. Pediatricians and surgeons should consider colon perforation as a cause in children who present with abdominal distention and a history of diarrhea for more than 5 days.

Postoperative Outcomes, and Growth and Brain Injury Outcomes in Spontaneous Intestinal Perforation vs Surgical Necrotizing Enterocolitis in Preterm Infants.

OBJECTIVE: To compare the clinical outcomes in preterm infants following surgical necrotizing enterocolitis (sNEC) and spontaneous intestinal perforation (SIP). METHODS: Retro-spective comparison of clinical information in preterm infants with sNEC and SIP admitted between January, 2013 and December 31, 2018. The clinical outcomes were compared in two groups, including postoperative and brain injury detected on brain magnetic resonance imaging (MRI) after clinical and histopathological confirmation of the SIP and the NEC diagnosis. RESULTS: 114 infants had sNEC, and 37 had SIP. Infants with SIP had lower median gestational age [25.1 weeks (23.5, 27.1) vs 26.6 (24.4, 31.0), P=0.03], an earlier mean (SD) age of disease onset [10.1 (11.3) days vs 19.6 (17.9); P<0.001] and lower maternal chorioamnionitis on placental pathology [4 (23.5%) vs 22 (68.8%); P=0.007), received more often Penrose drain therapy (54% vs 33%; P=0.03), had less median (IQR) bowel length loss [3.3 cm (1.72, 4.38) vs 21.4 (9.55, 35.3); P=<0.001] and had more often intact ileocecal valve (91.4% vs 65.7%; P=0.006] compared to those with sNEC. In addition, those with sNEC had lower median (IQR) weight z scores at the time of discharge [-1.88 (-2.80, -1.09) vs -1.14 (-2.22, -0.44); P=0.036] than SIP. There were no significant differences in postoperative ileus, duration of parenteral nutrition, surgical morbidity, length of stay, mortality, white matter, and grey matter injury on brain MRI at term equivalent age in preterm infants with SIP and sNEC. CONCLUSION: In our cohort, preterm infants with SIP and sNEC did not show significant differences in postoperative morbidity and brain MRI abnormalities at term equivalent age. sNEC had lower discharge weight z scores. Larger prospective studies are needed for confirmation of these findings.