Baffling perforation of the colon

Idiopathic perforation of the colon is extremely unusual and unexpected, with a very limited number of published reports. The condition's definition depends on the absence of any detectable pathology in the bowel wall that could be responsible for the perforation. A 62-year-old male patient presented with acute thrombosis of the brachial artery. This was successfully treated with an open thrombectomy and systemic anticoagulation, with rapid resolution of the symptoms. During the hospital stay the patient had regular bowel movements and no abdominal complaints. Suddenly he complained of acute abdominal pain. Physical examination and emergency CT scan of the abdomen were consistent with generalized peritonitis. Emergency laparotomy revealed two perforations of the mid-sigmoid colon, each measuring 1.5 x 1.5 cm, and located one in the antimesenteric aspect and one very close to the nutrient vessels. The edges of the perforations showed no inflammatory or necrotic changes. A 2.5 cm streak of macroscopically normal bowel wall was observed between the perforations. The rest of the bowel showed inflamed peritoneum with fibrin as a result of the peritonitis, but was otherwise normal. Sigmoid resection with a Hartmann's pouch was performed and the proximal colon was brought out in the form of an end-colostomy. The abdomen was thoroughly lavaged with warm saline and temporarily closed with plastic sheeting for second-look exploration. Bacteriology from the intra-abdominal fluid showed mixed abdominal flora and no unusual pathogens. The patient was returned to the operating room on five occasions 24-48 h apart for planned re-explorations and peritoneal irrigations. The abdominal wall was restored on postoperative day 12 once a macroscopically clean peritoneum was noted. The patient was transferred to an acute rehabilitation facility. He is known to be alive and recuperating more than eight months after the surgery. Pathology from the colon revealed an inflamed visceral peritoneum with fibrin and otherwise normal-looking mucosa. There were no diverticula. The edges of each perforation showed no alteration of the muscle or mucosa. Histology from both perforations demonstrated normal intestinal wall architecture, normal mesenteric structures including nutrient vessels and lymphatic tissue, and no specific condition responsible for the perforations. No changes suggestive for ischemia or any other pathology were noted (Figure 1). Idiopathic perforation of the colon is rare. The diagnosis depends on excluding other conditions that can potentially contribute to the condition's occurrence. No pathology that might have caused colonic perforation could be identified in our patient. It could be …