An 89-year-old Sudanese farmer was admitted to the emergency department with a 9-day history of generalized colicky abdominal pain, abdominal distension, anorexia, persistent vomiting, and constipation. The pain started in the left iliac fossa and periumbilical region then progressed to be generalized and colicky in nature. It was moderate to severe, mainly aggravated by eating, while partially relieved after vomiting and analgesia. It was associated with fever, anorexia, nausea, and vomiting. Eventually, the pain became diffuse, generalized, severe, and continuous, with abdominal guarding, distension, and absolute constipation for 1 day before the presentation. The systemic review was clear, apart from bilateral lower limb edema.
The patient had a previous history of left-sided and lower abdominal pain but no lower gastrointestinal symptoms, including bleeding. He had no history of weight loss or jaundice. He had a clear medical and surgical background. He was not allergic to any drugs or under any chronic medications.
On examination, he was fully conscious and oriented to time, place, and person. He was not pale or jaundiced. His presenting pulse rate in the ED was 108 beats per minute, normotensive with 130/70 mmHg blood pressure, and good hydration status. Abdominal examination revealed generalized abdominal distension with full flanks, and diffuse tenderness in all abdominal regions with guarding but no rigidity. There was no palpable organomegaly or masses. There were absent bowel sounds suggestive of severe generalized peritonitis and a bowel perforation. A digital rectal examination (DRE) revealed an empty rectum.
Blood analysis was requested which revealed hemoglobin of 12.6 g/dl, TWBCs of 22,000 × 103, mainly neutrophils, adequate platelets count, and C-reactive protein (CRP) of 189 mg/dl (normal value ≤ 3 mg/dl). The liver function test revealed low serum albumin of 2.3 g/dl (normal value 3.5–5 g/dl) with a preserved albumin globulin ratio. The carcinoembryonic antigen (CEA) tumor marker level was checked, as a perforated colorectal tumor was one of our top differentials, but it was within the normal range. Urinalysis and blood electrolytes were normal.
Erect chest and abdominal X-rays showed dilated bowel loops of the small and large bowel, cecal diameter of ≥ 12 cm, and free peritoneal/subdiaphragmatic gas (air under diaphragm).
Considering the patient’s clinical examination, radiology findings, and patient status, severe peritonitis due to large bowel perforation secondary to an obstructing left-sided tumor was the provisional diagnosis.
The colorectal surgeon’s decision was emergency surgical exploration. The contrast-enhanced computed tomography (CECT) of the abdomen was deferred, as it would delay the surgical exploration.
Management including intravenous fluoroquinolones and metronidazole antibiotics, fluids, and intravenous human albumin replacement was initiated. An emergency exploratory laparotomy through midline incision revealed a distended large bowel up to the level of obstruction, free intraperitoneal bowel contents, patchy ischemia of the lateral cecal wall with three perforations, and left-sided omento–epiploic extraluminal band causing distal descending colon obstruction (large bowel closed-loop obstruction) (Fig. 1).
Formal laparotomy and careful examination of the abdominal organs, cavity, and bowel were carried out. Furthermore, a simple release of the constricting band with diathermy, standard right hemicolectomy, and ileo-transverse functional end-to-end stapled anastomosis with linear GIA stapler reconstruction (Figs. 2 and 3) was performed. Finally, surgical toilet with warm saline was instilled, pelvic drain was kept in situ, and standard mass closure of the abdomen with size one monofilament, nonabsorbable polypropylene suture was accomplished.
Oral intake started on postoperative day 2 and advanced as tolerated by the patient, reaching regular dietary intake by day 7. However, wound infection with purulent wound discharge was discovered during the first dressing on day 3 with intact facial layer. The intraabdominal drain became dry on postoperative day 5.
The patient was discharged on day 9 with wound dressing protocol every other day. Regular dressing was done until the wound was clean by day 14. Surgical stitches were removed during the third postoperative week, and a 3-month follow-up was planned.
