A rare case report of iatrogenic caecal perforation.
On physical examination, she had tachycardia (pulse rate of 110/min). Abdomen was distended. There was generalized abdominal tenderness and guarding. Liver dullness was obliterated. The bowel sounds were absent. The haemogram showed leucocytosis (11000/Cu mm). Chest X-ray showed free air under the diaphragm. A preoperative diagnosis of hollow viscus perforation with peritonitis was made and the patient was taken up for emergency laparotomy.
On laparotomy, there was caecal perforation with faecal peritonitis. The perforation was 0.2 X 0.2 cm with healthy margins. There were no adhesions and rest of the bowel loops, appendix and liver and spleen were normal.
The suspicion of iatrogenic trauma due to prior orthopaedic intervention was anticipated and was discussed with the corresponding faculty regarding the same and medial direction of passage of guide wire was recollected.
The caecum was decompressed and primary repair of the perforation was performed in two layers. Peritoneal lavage done and pelvic drain was placed. Oral diet was started on post-operative day 5. Drain was removed on post-operative day 6. Patient post-operative recovery was uneventful and was discharged on post-operative day 12.
DISCUSSION: A Caecum perforation is a very rare identity. Traumatic caecal perforation are even rare. (1) Caecal perforations are usually seen associated with entities such as diverticular disease, inflammatory bowel diseases, ogilville syndrome, (2) closed loop obstructions, (3) pancreatic carcinomas, (4) colorectal cancers, (5) hirschsprung's disease, (6) rarely associated with foreign body, (7, 8) in burn patient, 99) tuberculosis infection (10) and following caesarean section (11, 12) or iatrogenic endoscopic procedure. Traumatic causes of caecal perforations are stab wounds, gunshot wounds, operative wounds and foreign body. (1)
Surgery for colonic perforation is associated with high morbidity and mortality rates. Simple closure of the perforation without exteriorizing the caecum was the procedure most used (1). Exteriorization of the caecum may be necessary when the duration of the perforation has been prolonged, and when fecal contamination is present. (1) These cases require added hospitalization, extra care for their caecostomy, and a second operation to re-place the caecum into the abdomen. Other surgical options are tube caecostomy, and right colectomy. (1)
In the present case, as the perforation size was small and margins were healthy, an attempt was made with primary repair even with peritoneal lavage and patient recovered uneventfully.
CONCLUSION: Iatrogenic caecal perforations are very rare and are documented usually following endoscopies. Caecal perforations following orthopaedic procedures have not been documented. Early diagnosis and prompt surgical repair of the perforation is necessary.
For small perforations, primary repair may be an option with least morbidity thus reducing the morbidity associated with exteriorization or caecostomy.
(1.) Join H. Albers, Louis L. Smiith, Richard Carter. Perforation of the Cecum. Annals of Surgery 1956 February; 143(2): 251-255.
(2.) Vanek VW, Al-Salti M: Acute pseudo-obstruction of the colon (Olgivie's syndrome): an analysis of 400 cases. Dis Colon Rectum 1986, 29:203-210.
(3.) Novy S, Rogers LF, Kirkpatrick W: Diastatic rupture of the cecum in obstructing carcinoma of the left colon. Radiographic diagnosis and surgical implications. Am J Roentgenol 1975, 123:281-286.
(4.) Tempia-Caliera AA, Horvath LZ, Zimmermann A, Tihanyi TT, Korc M, Friess H, Buchler MW: Adhesion molecules in human pancreatic cancer. J Surg Oncol 2002, 79:93-100.
(5.) Carraro PG, Segala M, Orlotti C, Tiberio G: Outcome of large-bowel perforation in patients with colorectal cancer. Dis Colon Rectum 1998, 41:1421-1426.
(6.) Yamamoto T, Hayashi Y, Suzuki H, et al: Early onset of cecal perforation in neonatal, rectosigmoid type Hirschsprung disease. Acta Pediatr Jpn 1994, 36:717-9.
(7.) Fielitz J, Ehlert HG: Perforation of the cecum by a toothpick-a rare differential acute appendicitis diagnosis. Case report and review of the literature. Chirurg 2000, 71(11):1405-8.
(8.) Renner K, Holzer B, Hochwarter G, Weihsbeck E, Schiessel R: Dig Surg. Needle perforation of the appendix 2000, 17(4):413-4.
(9.) Ghoneim IE, Bang RL: Caecal perforation in a burn patient. Burns 1995, 21(8):619-21.
(10.) Jain DK, Aggarwal G, Lubana PS, Moses S, Joshi N: Primary tubercular caecal perforation: a rare clinical entity. BMC Surg 2010, 10:12.
(11.) Wesch G, Ehrlich G, Storz LW, Wiest W: Two cases of perforation of the cecum following caesarean section. Geburtshilfe Frauenheilkd 1980, 40(2):116-20.
(12.) Durai R, Linsell J: Caecal perforation following a caesarean section. Br J Hosp Med (Lond) 2011, 72(5):290-1.
Suresh Huchchannavar 
[1.] Suresh Huchchannavar
PARTICULARS OF CONTRIBUTORS:
[1.] Assistant Professor, Department of Surgery, Karnataka Institute of Medical Sicnces, Hubli.
FINANCIAL OR OTHER COMPETING INTERESTS: None
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Suresh Huchchannavar, Assistant Professor, Department of Surgery, KIMS Hubli, Vidya Nagar, Hubli-580020, Karnataka.
Date of Submission: 14/02/2015.
Date of Peer Review: 16/02/2015.
Date of Acceptance: 23/02/2015.
Date of Publishing: 05/03/2015.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||CASE REPORT|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Mar 5, 2015|
|Previous Article:||Outcome of instrumental vaginal deliveries in referred cases.|
|Next Article:||A case report of mucinous adenocarcinoma colon presenting as right gluteal abscess.|