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Case
A 77-year-old female with a previous history of chronic renal failure due to amyloidosis (requiring hemodialysis) and high blood pressure suffered from anemia and transfusional requirement due to a positive fecal occult blood test. A colonoscopy was performed, identifying two polyps (7 and 5mm, Paris IIa Type) at the ascending colon. An indigo carmine injection and a diathermic snare were used for resection (FIG 1). After the procedure the patient presented with abdominal pain. During the evaluation the patient had stable vital signs, tenderness at the right flank, and the most relevant laboratory parameter was a PCR level of 7.78 mg/dL. Further investigation was carried with a Enema CT-scan that described diffuse pneumoperitoneum and some retropneumoperitoneum (VID 1). Contrast was administered by enema, which suggested a contained perforation in the retroperitoneum (VID 2).
Treatment
Initial conservative management was performed with nil by mouth, IV fluids and antibiotics. Clinical evaluation detected that the pain got worse, the patient started to have abdominal distention, and PCR levels increased. Surgical treatment was performed by laparoscopic approach using a total of 5 ports. Intra operative findings were: free abdominal turbid liquid and a swollen right colon. A right colectomy was performed with medial to lateral mobilization due to a thickened mesocolon. The ileocolic vessels were sectioned intracorporeally with a mechanical suture. Primary mechanical anastomosis was extracorporeally built as there was no peritonitis. The patient did not require vasoactive drugs and she had recently undergone bowel prep. The surgery took 120min and was uneventful.
Outcome
During the postoperative period the patient presented with intraluminal bleeding that was controlled by endoscopic revision (clip in the anastomosis). The patient left hospital 10 days after the surgery. The polyps were a tubular adenoma with low grade dysplasia. The perforation was identified at the resected colon. No other mucosal lesions were found.
FIG 1. Endoscopic polypectomy