Estudo retrospectivo da prevalência de perfurações gastrointestinais em pacientes submetidos a colonoscopias no Hospital Regional Hans Dieter Schmidt / Retrospective study of the prevalence of gastrointestinal perforation in patients submitted to colonoscopies at Hans Dieter Schmidt Regional Hospital

Introdução: A colonoscopia é um instrumento padrão ouro para triagem e identificação precoce do câncer colorretal. Embora relativamente segura, está sujeita a complicações, como a perfuração de cólon, vinculando-se com altas taxas de morbidade e mortalidade. Objetivos: Avaliar a prevalência de perfuração intestinal em realização de colonoscopias entre os anos de 2012 e 2017 no Hospital Regional Hans Dieter Schmidt, em Joinville-SC e traçar um perfil dos sujeitos que sofreram perfuração, fatores de risco associados, caracterização do exame (diagnóstico ou terapêutico) e seus respectivos desfechos clínicos. Métodos: Estudo quantitativo, descritivo, retrospectivo e transversal, com coleta de dados realizada por análise de prontuários eletrônicos, resultados de colonoscopias e laudos anatomopatológicos. Resultados: Entre 2012 e 2017 foram realizadas 898 colonoscopias, sendo registradas 9 perfurações (1,00%), sendo 4 em mulheres e 5 em homens. Destas, 8 (0,89%) foram com intuito diagnóstico e 1 (0,11%) teve objetivo terapêutico. As faixas etárias variavam entre 46 e 76 anos, sendo a hipertensão arterial sistêmica (55,55%) e a realização de cirurgias prévias (55,55%) os fatores de risco mais encontrados. Os diagnósticos das perfurações foram realizados por meio de laparotomia, e o tratamento foi realizado conjuntamente ao diagnóstico. Cinco casos evoluíram a óbito após a realização do tratamento, um para sepse e outro para peritonite fecal. Conclusão: Perfurações secundárias a exame de colonoscopia apesar de escassas, porém cursar com complicações graves, como sepse, peritonite fecal e até mesmo óbito.

câncer diagnosis. Though it is a relatively safe exam, it is not free of complications, such as colon perforation, which presents a high morbimortality rate. Objectives: Investigate the prevalence of perforation in subjetcs who went through colonoscopy in the Regional Hospital Hans Dieter Schmidt, located in Joinville (SC) during 2012-2017 and their epidemiologic profile, including risk factors, exam intention (therapeutic or diagnosis) and respective outcomes. Methods: Cross-sectional, descriptive, quantitative and retrospective study, whose data were collected from medical registers of colonoscopy outcomes and anatomopathologic reports. Results: During 2012-2017 period, 898 colonoscopies were conducted and 9 perforations (1,00%) cases were observed, four in men and five in women. Among those, eight (0,89%) aimed diagnosis and one (0,11%) was therapeutic. Age of subjects who suffered perforation ranged from 46 to 76 years and systemic arterial hypertension and previous surgery were the most present risk factors (55,55% each). Perforation cases were detected by laparotomy and the management was instituted right after diagnosis. Five cases resulted in death after treatment, one progressed to sepsis and other to fecal peritonitis. Conclusion: Perforation due to colonoscopy, though rare, might progress to serious complications, like sepsis, fecal peritonitis and even death.

Perforación de sigma secundaria a migración de prótesis biliar / Sigma Perforation Secondary to Migration of Biliary Prosthesis

RESUMEN Introducción: La migración de una prótesis en la vía biliar es una complicación muy poco frecuente que normalmente se expulsa de forma natural, pero en raras ocasiones puede cursar con complicaciones severas. Objetivo: Describir una complicación rara por migración de una prótesis biliar. Caso clínico: Se presenta un paciente de sexo masculino de 75 años, portador de stent biliar que presenta una perforación de sigma secundaria a migración de la prótesis. Conclusiones: Las migraciones protésicas deben vigilarse y si no se eliminan de manera espontánea o el paciente presenta síntomas, se debe proceder a su retirada endoscópica o quirúrgica(AU)

ABSTRACT Introduction: Migration of a prosthesis in the bile duct is a very rare complication normally expelled in a natural way, but on rare occasions it can lead to severe complications. Objective: To describe a rare complication due to migration of biliary prosthesis. Clinical case: A case is presented of a 75-year-old male patient with a biliary stent who presented a sigmoid perforation secondary to migration of the prosthesis. Conclusions: Prosthetic migrations should be monitored and, if they are not eliminated spontaneously or the patient presents with symptoms, they should be removed endoscopically or surgically(AU)

Colorectal Perforation After Anorectal Manometry for Low Anterior Resection Syndrome

We experienced 3 cases of manometry-induced colon perforation. A 75-year-old man (case 1) underwent anorectal manometry (ARM) 3 years after radiotherapy for prostate cancer and a laparoscopic intersphincteric resection for rectal cancer. A 70-year-old man (case 2) underwent ARM 3 months after conventional neoadjuvant chemoradiotherapy and a laparoscopic low anterior resection for rectal cancer. A 78-year-old man (case 3) underwent ARM 2 months after a laparoscopic intersphincteric resection for rectal cancer. In all cases, a colon perforation with fecal peritonitis occurred. All were treated successfully using prompt and active operations and were discharged without any complications. ARM with a balloon, as a measure of rectal compliance, should be performed 2 months or longer after surgery. If a perforation occurs, prompt and active surgical intervention is necessary due to the high possibility of extensive fecal peritonitis.

Invasive Primary Colonic Aspergillosis in the Immunocompetent Host without Classical Risk Factors

Invasive aspergillosis (IA), generally considered an opportunistic infection in immunocompromised hosts, is associated with high morbidity and mortality. IA commonly occurs in the respiratory tract with isolated reports of aspergillosis infection in the nasal sinuses, central nervous system, skin, liver, and urinary tract. Extra-pulmonary aspergillosis is usually observed in disseminated disease. To date, there are a few studies regarding primary and disseminated gastrointestinal (GI) aspergillosis in immunocompromised hosts. Only a few cases of primary GI aspergillosis in non-immunocompromised hosts have been reported; of these, almost all of them involved the upper GI tract. We describe a very rare case of IA involving the lower GI tract in the patient without classical risk factors that presented as multiple colon perforations and was successfully treated by surgery and antifungal treatment. We also review related literature and discuss the characteristics and risk factors of IA in the immunocompetent hosts without classical risk factors. This case that shows IA should be considered in critically ill patients, and that primary lower GI aspergillosis may also occur in the immunocompetent hosts without classical risk factors.

Endoluminal Closure of Colon Perforation with Endoscopic Band Ligation: Technical Feasibility and Safety in an In Vivo Canine Model

BACKGROUND/AIMS: Endoscopic band ligation (EBL) is an accepted method in the management of variceal bleeding; however, there is little evidence on the safety and feasibility of EBL for the closure of bowel perforation. In this study, we aimed to evaluate the technical feasibility and efficacy of EBL in iatrogenic colon perforation by using a canine model. METHODS: We established an iatrogenic colon perforation model by using seven beagle dogs. Longitudinal 1.5- to 1.7-cm colon perforations were created with a needle knife and an insulated-tip knife, and the perforation was subsequently closed with EBL. During a 2-week follow-up period, the animals were carefully monitored and then euthanized for pathologic examination. RESULTS: The EBL of iatrogenic colon perforations was successful in all dogs. The mean procedure time for EBL closure with one to three bands was 191.7 seconds, and there were no immediate complications. One animal was euthanized after 3 days because of peritonitis. There were no clinical and laboratory features of sepsis or peritonitis in the remaining six animals. On necropsy, we did not find any fecal peritonitis, pericolonic abscess formation, or transmural dehiscence at the perforation site. Histopathology demonstrated inflamed granulation tissue and scar lesions replaced by fibrosis. CONCLUSIONS: EBL might be a feasible and safe method for the management of iatrogenic colon perforations in an in vivo model.

A Case of Successful Endoscopic Clipping for Iatrogenic Colon Perforation Induced by Peritoneal Catheter Insertion / 대한소화기학회지

Advanced cancer patients with refractory ascites often do not respond to conventional treatments including dietary sodium restriction, diuretics, and repeated large volume paracentesis. In these patients, continuous peritoneal drainage by an indwelling catheter may be an effective option for managing refractory ascites with a relative low complication rate. Peritoneal catheter-induced complications include hypotension, hematoma, leakage, cellulitis, peritonitis, and bowel perforation. Although bowel perforation is a very rare complication, it can become disastrous and necessitates emergency surgical treatment. Herein, we report a case of a 57-year-old male with refractory ascites due to advanced liver cancer who experienced iatrogenic colonic perforation after peritoneal drainage catheter insertion and was treated successfully with endoscopic clipping.

A Case of Pneumorrhachis and Pneumoscrotum Following Colon Endoscopic Submucosal Dissection

Endoscopic submucosal dissection has been a useful treatment of selected colorectal neoplasia cases. The incidence of perforation related to colorectal endoscopic submucosal dissection is 5-20%. However, while there have been numerous reports regarding retroperitoneal, mediastinal, pleural and subcutaneous emphysema after therapeutic colonoscopy, pneumoscrotum is a relatively rare manifestation of perforation associated with colorectal endoscopic submucosal dissection. In particular, pneumorrhachis, or air within the spinal cord, following therapeutic colonoscopy, is extremely rare. Herein, we report a conservatively treated perforation case as having pneumorrhachis, penumoscrotum, and pneumoperitoneum after colorectal endoscopic submucosal dissection.

Colonoscopic Perforation During a Diagnostic Colonoscopy / 대한소화기내시경학회지

BACKGROUND/AIMS: Colonoscopy is a useful method for detecting colorectal disease, but complications are on the rise due to the increasing number of colonoscopies. The aim of this study was to analyze colon perforations following diagnostic colonoscopies. METHODS: We performed retrospective reviews of all patients with colonoscopic perforations between January 2000 and June 2010. RESULTS: Of 25,883 diagnostic colonoscopies performed, seven cases of colon perforations were reported. Among those, five cases had an abdominal operation history; the site of perforation was the sigmoid colon in three cases and the rectum in four cases. The manipulation type was forward viewing in three cases and retroflexion in four cases. The time to diagnosis was immediate in six cases and delayed in one case, and treatment was conservative management in three cases and surgical management in four cases. CONCLUSIONS: Special attention is required for patients with a previous abdominal operation and retroflexion. Even after perforations occur, favorable outcomes can be obtained by conservative treatment if the patient's condition is stable, the bowel preparation is proper, and there are no signs of peritonitis.

A Case of a Colon Perforation Due to a Soft Rectal Foreign Body / 대한소화기내시경학회지

Numerous foreign bodies in the rectum have been reported in the literature. Their removal can be challenging depending on the size and shape of the objects and their anatomical location in the rectum. A 64-year-old man presented to the emergency department after inserting a sausage into his rectum. He had some rectal discomfort and lower abdominal pain. There were no signs of bowel perforation. We attempted to extract the sausage impacted in the recto-sigmoid junction by colonoscopy using a snare and grasping forceps but failed to extract the foreign body. Unfortunately, a colon perforation had occurred, and the sausage was eventually extracted by performing a colostomy at the recto-sigmoid junction with primary repair. We report this case of a soft rectal foreign body impacted in the recto-sigmoid colon complicated by a colon perforation with a literature review.

Penetration of the Descending Colon by a Migrating Intrauterine Contraceptive Device

Foreign bodies in the gastrointestinal tract often cause serious complications, such as perforation, obstruction, abscess formation, or hemorrhage. This is a case in which a patient visited our hospital and complained of a vague lower abdominal pain that had been present for three months. She had an intrauterine device (IUD) inserted five years earlier. The abdominal X-ray, computed tomography and colonoscopy revealed that the IUD had penetrated into the descending colon. We tried to remove the IUD by colonoscopy but failed due to pain, so we removed the IUD surgically. Thus, we report a case in which a previously inserted IUD had penetrated into the descending colon and was surgically removed. We also present a brief review of the literature.

Colonoscopic Perforation; A 10-year Experience in Single General Hospital / 대한소화기학회지

BACKGROUND/AIMS: Colonoscopy is the principal method for diagnosis, treatment, and follow up of colorectal disease. The study aimed to assess the incidence, clinical features, and management of colonoscopic perforations at a local general hospital. METHODS: A retrospective review of patient record was performed for all patients with iatrogenic colonic perforation after sigmoidoscopy and colonoscopy between 1997 and 2007. RESULTS: In the 10-year period, 16,388 colonoscopic and sigmoidscopic procedure were performed. All 10 cases of procedure related colonic perforation were developed. Perforation occurred in 9 cases during therapeutic procedure; 5 cases due to polypectomy and 4 cases due to endoscopic submucosal dissection. Perforation occurred in one case during diagnostic procedure. CONCLUSIONS: Therapeutic procedure is a clear risk factor of colonic perforation. When colonic perforation occurs, we should be able to make early diagnosis. Early diagnosis can lead to a good treatment and can produce good prognosis with short hospital days.

A Case of Successful Percutaneous Drainage of a Pelvic Abscess Complicating Colonoscopy

Perforations that occur during colonoscopy are usually managed by surgical repair. When the patient's symptoms are mild and laboratory findings show minor abnormalities, a conservative treatment can be considered. Although an operation is the treatment of choice in patients with generalized peritonitis, in some selected patients, percutaneous abscess drainage can be an alternative to surgical intervention for drainage of deep-infected fluid collections or can act as a temporary measure until the patient becomes sufficiently stable for surgery. We report here on a 53-yr-old male patient who developed signs of localized peritonitis and had a pelvic abscess due to a colonic perforation after colonoscopy and was treated successfully by using percutaneous abscess drainage.

A Case of Transverse Colon Perforation after Colonoscopy in a Patient withEnterocolitis Caused by Non-typhoidal Group D Salmonella / 대한소화기내시경학회지

Clinical manifestations of Salmonella infection are variable such as enterocolitis, bacteremia, enteric fever, focal infection and asymptomatic carrier status. Among these presentations, enterocolitis is the most common clinical manifestation and can be diagnosed by the use of fecal specimens. Patients with severe infectious colitis are at increased risk of developing a colon perforation after colonoscopy due to colon trauma. We report a case of a 31-year-old woman with transverse colon perforation after colonoscopy that was diagnosed with enterocolitis caused by infection with non-typhoidal group D Salmonella.

Treatment of Colon Perforation Associated with Colonoscopy

PURPOSE: Recently, non-operative conservative management or laparoscopic repair has been reported for the management of colonic perforation during colonoscopy. However, the preferred management strategy remains controversial. The purpose of the present study is to identify an appropriate strategy for the treatment of colon perforation during colonoscopy. METHODS: The medical records of patients who developed colon perforation during colonoscopy between May 2003 and November 2007 were retrospectively reviewed. The mechanism and site of perforation, the treatment administered, complications, and clinical outcomes were analyzed. RESULTS: In total, 16 perforations were evaluated. Of these, 11 developed during diagnostic colonoscopy and 5 during therapeutic colonoscopy. The most frequent perforation site was the sigmoid colon (12), followed by the transverse colon (2), the rectum (1), and unknown site (1). Six patients underwent surgery due to signs of diffuse peritonitis 10 were initially treated conservatively. Among the patients who underwent surgery, four underwent laparoscopic repair and two underwent open repair. Among the patients initially treated conservatively two patients required surgery due to clinical deterioration of peritonitis and rectovaginal fistula. These 2 patients underwent repair with proximal diverting stomas. CONCLUSIONS: Colon perforation associated with colonoscopy is a rare event, but raises serious complications. Selected patients with colonoscopic perforation may be treated conservatively, but if these patients fail to respond to such treatments, extensive surgical procedures may be warranted.

Pneumatosis Cystoides Intestinalis in Patients with Antinuclear Antibody Negative Systemic Lupus Erythematosus and Dermatomyositis: Report of Two Cases

Pneumatosis cystoides intestinalis (PCI) occurring in association with collagen vascular disease is an unusual combination that presents with intramural gas in the gastrointestinal tract. We report two cases of PCI, one with antinuclear antibody (ANA) negative SLE and the other with dermatomyositis, with a review of the relevant literature.

A Case of Tension Pneumoperitoneum as a Fatal Complication of Colonoscopy / 대한법의학회지

Tension pneumoperitoneum (TP) is a rare fatal complication of colonoscopy. In a forensic point of view, this complication is hard to be diagnosed as a cause of death simply considering the result of autopsy findings without clinical information. We experienced an autopsy case expired by TP resulting from colonic perforation during colonoscopy. A 51-year-old woman was performed a colonoscopy under the sedation with propofol. The physician could not find any pathologic lesions throughout the whole colonic mucosa and noticed a perforation at sigmoid colon when he was about to wrap up his procedure. The patient was immediately transferred to the emergency department and showed distended abdomen with unstable vital signs. Although she was taken emergency exploratory laparotomy and simple closure of the perforated site, she died at 3 days after operation due to multiple organ failure. At autopsy, we could not find any other pathologic abnormality except for a wellsutured perforated site. However, the clinical findings and course enabled us to come to conclusion that the cause of death was TP. In conclusion, when conducting an autopsy on the death after colonoscopy, we should consider the possibility of TP by leakage of large amount of air during colonoscopy.

Conservative Treatment of Colonoscopic Perforations / 대한소화기내시경학회지

BACKGROUND/AIMS: Colonoscopic perforation can be treated by both operative or non-operative methods. Non-operative management, and especially conservative management, may be appropriate for selected individuals. We wanted to verify the usefulness of performing conservative management for treating colonoscopic perforations. METHODS: We reviewed the medical records of the colonoscopic perforation cases that occurred in the recent 5 yrs. 11 cases of perforation occurred from among 8,536 colonoscopic procedures. RESULTS: Ten cases occurred from a therapeutic procedure (five from polypectomy and another five occurred from an endoscopic (submucosal dissection) and one case occurred from a diagnostic procedure. The perforation sites were the ascending colon (three cases), transverse colon (two cases), descending colon (one case), sigmoid colon (two cases), and rectum (three cases). There were five intraperitoneal perforations and five retroperitoneal perforations. All the cases were detected within 12 hours and all the cases had received good bowel preparation. 10 cases were managed conservatively (nothing by mouth, broad spectrum antibiotics and, Levin tube suction). One case was managed by an operative procedure due to the large size of the defect and the patient's wish. All the patients recovered without complications. The mean hospital stay was 9.5 days. CONCLUSIONS: Colonoscopic perforation can managed conservatively in selected cases, such as for those cases that will undergo post-therapeutic colonoscopy and those cases that have undergone good bowel preparation.

A Case of Successful Endoscopic Therapy in Iatrogenic Perforation of the Colon during Colonoscopy / 대한소화기내시경학회지

Colonoscopy is a safe and standard procedure for diagnosis and therapy of colonic disorders. Iatrogenic colonic perforation during diagnostic colonoscopy, a rare abdominal emergency, has an 0.3~0.8% incidence rate. The choice of treatment for this complication remains controversial. Prompt operative intervention is preferred to minimize morbidity and mortality. However, operative intervention is invasive and needs a long-term recovery period. Conservative treatment is less invasive but can lead to more extensive surgery in case of treatment failure. Very important point on the treatment of iatrogenic perforation of the colon during diagnostic colonoscopy is to avoid the leaking of intestinal contents into the intraperitoneal cavity. We report here a case in which an iatrogenic perforation of the colon during diagnostic colonoscopy was successfully treated by endoscopic clip therapy.

Prognostic Factors for Generalized Peritonitis Secondary to Colonic Perforation

PURPOSE: The prognosis following colonic perforation is generally regarded as worse than it is for upper gastrointestinal perforation. Moreover, the increasing incidence of colon cancer associated perforation is another reason for the present study of colonic perforation in the present study. We reviewed and analyzed various types of colonic perforations to determine which prognostic factors were still useful for the treatment of colonic perforation. METHODS: Thirty six patients (mean age, 51.5; 24 males) with generalized peritonitis secondary to a colonic perforation were studied retrospectively. All the patients had undergone an exploratory laparotomy. The severity of the clinical condition was recorded according to the APACHE III scoring system for all the patients when they were first seen. Mortality and morbidity were analyzed for possible prognostic factors, such as age, type of operation, association with malignancy, and APACHE-III score. RESULTS: Penetrating trauma was the leading cause of perforation (27.8%), and iatrogenic perforations accounted for 19.4% of the total. Among nontraumatic perforations, malignancy was the major pathology (25.0%). The sigmoid colon was the most frequent site of perforation. Types of surgical treatment varied according to the general conditions of the patients. In 22 patients, the operation was finished with primary closure alone. A colonic resection was performed in 14 patients, and a proximal diversion was performed in 19 patients (after either a resection or primary closure). Analysis of the various clinical variables showed that old age (>60), underlying malignancy, and the APACHE III score were significant prognostic factors for the surgical outcome. CONCLUSIONS: These results suggest that penetrating injuries are still the main cause of colonic perforation and that iatrogenic and malignancy-related perforations are increasing. Among other variables, old age, underlying malignancy and the APACHE III score are significant prognostic factors for the surgical outcome.

Non-Traumatic Colon Perforation

PURPOSE: Despite advances in surgery, antimicrobial therapy and postoperative intensive care, severe secondary peritonitis, caused by colonic perforation, remains a potentially fatal affliction. The appropriate surgical management of colonic perforation has always been a controversial issue, and one that continues to evolve. The differences in patient's characteristics, due to their medical problems, general conditions, peritonitis grade, or causes of perforation, influence both the surgical decision and the outcome. The aim of this study was to evaluate and compare the incidence, management and outcome of patients with different causes of non-traumatic colon perforation. METHODS: Between February 1993 and February 2002, 42 patients underwent emergency operations for non-traumatic colon perforations. We compared the morbidity and mortality with age, cause, perforation site, extents of peritonitis and surgical procedure. In patients with colorectal-cancer, we assessed the outcomes as perforation types; the perforation of the tumor itself, diastatic perforations proximal to an obstructing tumor and tumor stages. RESULTS: The causes of perforation were cancerous in 17 (40.5%), idiopathic in 7 (16.7%), diverticular in 5 (11.9%), colitis in 4 (9.5%), adhesion and strangulation in 4 (9.5%), stercoral in 3 (7%) and enema induced in 2 (4.8%). The morbidity and mortality in this study was high 76.2 and 26.2%, respectively. The morbidity and mortality was increased as the intra-abdominal fecal contamination increased (P<0.05). but there were no correlations between the complication rate, age, cause, perforation site or operation procedure. In patients with colorectal cancer, there were no correlations between the morbidity and mortality, perforation type or tumor stages. CONCLUSION: A non-traumatic colon perforation is associated with high morbidity and mortality. The prognosis of patients is determined by the grade of their peritonitis. Early diagnosis and prompt surgical management will result in better outcomes for patients with non-traumatic colon perforations.