Idiopathic perforation of the transverse colon in an adult: a case report and literature review

True idiopathic perforation of the colon in the adult is both a rare and unusual clinical entity. As the name suggests, there is no identifiable cause making this a diagnosis of exclusion. Due to its rarity, it is difficult to establish causality between the disease and associated patient factors. Mortality of this disease is secondary to the resulting fecal peritonitis and can be reduced by early recognition and timely surgical intervention. Introduction Idiopathic perforation of the colon, also referred to as spontaneous colonic perforation is an extremely rare disease in both adults and neonates. It is defined as perforation of the colon without identifiable etiology. As a result, it is a diagnosis of exclusion and can only be made after exhaustion of all other possible causes. We report a case of a 50 year old female who presented to us with colonic perforation without an identifiable cause. Case description A 50 year old female who is a known diabetic presented to our institution with a sudden onset severe abdominal which became generalized with a duration of 6 hours. The pain was described as 10/10 severity, constant, non-radiating, aggravated by movement with relief on lying still. There were no associated factors. Her surgical history was unremarkable with her drug history revealing oral hypoglycemic use with no ASA or NSAID use. Of note, she has a 36 pack year smoking history and drinks 3 nips (30 ml = 1 nip) of puncheon rum (no less than 75% of alcohol by volume) daily for many years. Examination revealed an ill looking, malnourished female in moderate painful distress. BP: 134/68 mmHg, P: 105, regular, respiratory rate: 20 breaths/min with the remaining vitals within normal limits. Abdominal examination revealed generalized tenderness with board like rigidity, guarding and rebound tenderness. Digital rectal exam was unremarkable. The remaining physical exam was unremarkable. Laboratory results revealed: WBC: 12.5, Hemoglobin: 12.6, Platelet: 159, Cr: 2.3, BUN: 45, electrolytes: within normal limits, ABG: anion gap metabolic acidosis, Abdominal X-ray revealed a pneumoperitoneum and pancreatic calcification (Figure 1). Following adequate resuscitation, the patient underwent an exploratory laparotomy. Intra-operative findings included: feculent peritonitis with approximately 1.0 L of free fluid, an approximately 2 cm perforation in the proximal transverse colon a few cm distal to the hepatic flexure on the anti-mesenteric border (Figure 2). No diverticulae, signs of ischemia or necrosis, foreign bodies, palpable masses or hard fecal matter was noted. After a thorough lavage, a right hemicolectomy and ileo-transverse anastomosis was performed. The patient expired day 4 post operation form multi-organ dysfunction. Histologic examination of the specimen revealed no evidence of inflammatory bowel disease, no signs of ischemia or necrosis, the broken ends of the muscle are regular with non-specific changes in the mucosa (Figures 3-5). Discussion Idiopathic perforation of the colon is defined as a spontaneous perforation of the colon in the absence of disease. In 1872, it was first reported by Sir Benjamin Brodie [1]. Colonic perforations are usually the result of diverticulitis, malignancy, inflammatory bowel Correspondence to: Dr. Shariful Islam, MBBS, DM, General Surgery, San Fernando General Hospital; Trinidad & Tobago, West Indies, Tel: 868-797-4951; E-mail: [email protected]