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Perforated diverticulitis with free gas in peritoneal and retroperitoneal spaces

Case contributed by Vikas Shah
Diagnosis certain

Presentation

Lower abdominal pain, fever and raised inflammatory markers.

Patient Data

Age: 45 years
Gender: Male

Lungs and pleural spaces are clear. Abnormal streaky linear gas lucencies in paraspinal distribution in upper abdomen. 

There are a few scattered sigmoid diverticula, and a large volume of air appearing to arise from the surface of the sigmoid colon and extending superiorly into the retroperitoneal and peritoneal compartments. Small volume of fat stranding in the pericolic tissues, with no fluid collection or abscess. No fistula. Incidental fatty liver and umbilical hernia.

Histology report

Clinical History: Perforated sigmoid diverticulitis into mesentery

Macroscopic: Sigmoid colon - 220 mm length of large bowel with surface exudate and hemorrhagic mesentery. There is a perforation 180 mm from one end.

Microscopic: Microscopy confirms perforated diverticular disease with active chronic inflammation and extensive peritonitis. There is no dysplasia or evidence of malignancy. Both margins appear viable.

Conclusion: Sigmoid colon - perforated diverticular disease

Case Discussion

Complications of diverticular disease include inflammation, abscess formation, fistula formation, thrombophlebitis, and perforation. Gas may be present within the peritoneal or retroperitoneal compartments, or both as in this case. Although a difficult pick up on the CXR, there is abnormal paraspinal lucency that is appreciated on the subsequent CT to be due to retroperitoneal free gas.

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