Due to having strong, diffuse abdominal pain, a 56-year-old man heads off to the emergency department. The man has tachycardia and hypothermia, but his cardiopulmonary state is stable. The pain has persisted for 14 hours; its intensity is still increasing. The abdominal wall of the patient is very tense and tender to touch.
The search for the focus
The laboratory study shows noticeable lactic acidosis. The patient's pre-existing conditions include bipolar disorder, alcoholism and diverticulosis. For four days he has also suffered from constipation, which he has tried in vain to treat with various home remedies, he says.
Looking at a CT, the doctors see a fluid accumulation along the colon ascendens in the retroperitoneum. In addition a volume of air is present, both there and in the mediastinum.
On the basis of this finding, the doctors decide to conduct an explorative laparotomy. Parts of the colon ascendens turn out to be gangrenous; the caecum is perforated. A large amount of stool has spread out over the perforation along the mesentery. The surgeons remove the caecum and colon ascendens and rinse the abdomen.
They send the excised section to pathology. They report that there is no evidence of malignancy in the affected intestinal tract, nor are obstructions, diverticula or polyps found. In addition, since the patient does not suffer from chronic inflammatory bowel disease and has had no colonoscopy recently, nor taken drugs such as ipilimumab, the doctors continue to investigate the possible cause of the bowel wall rupture.
Unusual measure
In the end, they come across one of the so-called "home remedies" with which the patient tried to eliminate his constipation. He says that he tried to pull the stool through with suction force using a drainpipe plunger intended for use in the toilet.
Since such a commercially available "Pömpel" plunger moves 650 ml of air per application, the treating physicians consider it probable that the compressed air introduced to the intestine led to the perforation of the caecum. Pressure trauma in the intestine is in general not uncommon, they write in their report. However, the location of the rupture is so specifically unusual that when such a finding is found, unusual pathomechanisms should be considered, they write.
Source: Jonathan Rubin et al. / JSCR / docc.hk/yb56km
