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A Story of Extraordinary Abdominally Perforation.


More than 90 percent of pneumoperitoneum cases are the result of gastrointestinal perforations (1). Perforation of the stomach or the duodenum due to peptic ulcer is admitted as the most common cause of pneumoperitoneum. It also occurs because of abdominal trauma or diverticular perforation (1). The most common radiological finding in a patient with widespread peritonitis is free air under the diaphragm on chest X-ray. Most situations require immediate exploration and intervention. Iatrogenic colorectal perforations have frequently taken place in the surgical literature, due to occurring during colonoscopy and barium enema examinations (5). Rarely, pneumatic injuries caused by the jokes made with compressed air sources has also been reported (6). Rarely, pneumatic colon injuries caused by the jokes made for the fun using compressed air sources has also been reported (6).

Case report

An 89-year-old male patient was brought to the emergency room with the complaint of abdominal pain which started about 2 hours ago. According to the medical history taken from patient and his relatives, the patient has complained about chronic constipation for many years. When we detailed the medical history, we learned that the patient has complained about constipation for a long time, he has went to the toilet, attached the hose to the faucet, put the hose into his anus and opened the faucet to get the feces output by the help of the water. The patient said that he had done the same process for the abdominal pain began 2 hours ago. There are pain and tenderness in the abdominal examination of the patient. The patient's vital parameters including blood pressure, pulse, respiratory rate and fever were respectively measured as 90/52 mmHg, 74 / min, 20 / min fever and 36.4[degrees]C. In the lab tests of the patient, the hemogram parameters were like that: White blood cell (WBC): 11x10^9/ L, hemoglobin (HB): 14.5 g/dL, hematocrit (HTC): 42% and PLT: 427x10^9/L. The biochemical parameters were like that: glucose:113 mg/dL, sodium: 129 mmol/L, calcium: 8 mg/dL, total bilirubin: 1.52 mg/dL, direct bilirubin: 0.58 mg/d L and albumin: 2.8 g/ dL. C-reactive protein (CRP) was 0,401 mg/dL (normal range is 0 - 0.35 mg/ dL). Other parameters were normal. The patient's abdominal ultrasonography showed that there was approximately 10 centimeter free liquid in the lower abdomen. There was a diaphragmatic free air in the patient's chest and abdomen X-ray (Figure-1) and contrast-enhanced abdominal tomography showed images compatible with intraabdominal free fluid, pneumoperitoneum and perforation (Figure-2).The patient was consulted general surgery department and the he was undergone emergency surgery with the pre-diagnosis of pneumoperitoneum and perforation by general surgeons.


More than 90 percent of pneumoperitoneum cases are the result of gastrointestinal perforations (1). Perforation of the stomach or the duodenum due to peptic ulcer is admitted as the most common cause of pneumoperitoneum. It also occurs because of abdominal trauma or diverticular perforation (1). Complaints of constipation and chronic laxative use increase with age, and at the same time, there is an increase in the frequency of enema applied in emergency services, in nursing homes or at home by the patient him- or herself (2-3). Rectal tubes or similar instruments with varying length, diameter and stiffness are used for enema administrations performed with water or laxatives. The incidence of rectum and sigmoid colon perforations is increasing due to enema administrations performed by such tools (4). Paran et al reported 13 patients who consulted their clinic within 3 years for colorectal perforation due to enema in the study conducted in Israel. Ten of them were elderly patients with chronic constipation who were staying at nursing homes and the enema was administered by nursing staff. The other 3 patients administered the enema him- or herself at home. Considering the elderly patients with chronic constipation in our country, pneumoperitoneum cases which are secondary to colonic perforation caused by enema administrations should be drawn attention and further studies are needed. To inform patients relatives or caregivers who are taking care of them about possible injuries will also be useful.


A 4 cm sigmoid colon perforation which is extending 30 cm proximal from rectum was found in the operation performed by general surgeons. Pneumoperitoneum, which is the result of colonic perforation, has been found to show a mortal course especially in elderly patients, and pneumoperitoneum, which is caused by the perforation of the sigmoid colon after a traumatic procedure performed by the patient in our case, is worthy of presentation.


(1.) Mularski RA, Ciccolo ML, Rappaport WD. Nonsurgical causes of pneumoperitoneum.West J Med 1999; 170: 41-46.

(2.) Harari D, Gurwitz JH, Avorn J, et al. Constipation: assessment and management in an institutionalized elderly population. J Am Geriatr Soc. 1994; 42: 947-952

(3.) Harari D, Gurwitz JH, Minaker KL. Constipation in the elderly. J Am Geriatr Soc. 1993; 41: 1130-40

(4.) Paran H, Butnaru G, Neufeld D, et al. Enema-induced perforation of the rectum in chronically constipated patients. Dis Colon Rectum 1999; 42: 1609-1612

(5.) Gedebou TM, Wong RA, Rappaport WD, et al. Clinical presentation and management of iatrogenic colonperforations. Am J Surg 1996; 172: 454-458

(6.) Suh HH, Kim YJ, Kim SK. Colorectal injury by compressed air - a report of two cases. J Korean Med Sci1996; 11: 179-82.

Muhammed Ekmekyapar (1), Jukru Gurbuz (1), Serdar Derya (1), Hakan Oguzturk (1), Neslihan Yucei (1), Muhammet Gokhan Turtay (1) Abdullah Ercan (1), ismail Okan Yildirim (2)

(1) Department of Emergency Medicine, Inonu University, Malatya, Turkey(

(2) Department of Radiology, Inonu University, Malatya, Turkey

Corresponding Author: Jukru Gurbuz e-mail:

Received: 17.01.2019 x Accepted: 17.01.2020

DOI: 10.33706/jemcr.514083

[c]Copyright 2020 by Emergency Physicians Association of Turkey - Available online at
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Author:Ekmekyapar, Muhammed; Gurbuz, Jukru; Derya, Serdar; Oguzturk, Hakan; Yucei, Neslihan; Turtay, Muhamm
Publication:Journal of Emergency Medicine Case Reports
Article Type:Clinical report
Geographic Code:7TURK
Date:Jan 1, 2020
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