Pitfalls in Diagnosis and Treatment by Small Bowel Interloop Abscess From Sigmaperforation in The Middle of “Frozen Abdomen” A Case Report

Abstract

Case Report Introduction: The purpose of this article is to illustrate and discuss the various etiologies of intra-abdominal abscess from perforation of bowel and associated findings on abdominal CT. In such cases diagnosis and treatment still remain a possible pitfall and great challenge. A better understanding of intra-abdominal abscess pathophysiology, earlier diagnosis and adequate treatment reduced morbidity and mortality. Case Report: A 78-year-old male patient was admitted at Emergency Department with an acute abdomen, pain in his middle side of abdomen for about 3-4 days. A history of abdominal median laparotomie owing to intestinal obstruction (many years ago) was revealed. The CT examination was interpreted as a small bowel perforation. Note that the sigmoid colon contains several diverticula but does not appear acutely inflamed, no extraluminal contrast-discharge. The emergency laparotomy revealed an “frozen abdomen”, also ileum necrosis and perforation and interloop abscess was identified. There was no other fluid-discharge from mesentery/retroperitoneum. A wedge resection of the ileum was performed. Please note that to avoid more intestinal damage, the completely abdominal adhesiolysis was not performed. After 8 days, an anastomotic leak was excluded by fieber and chills. CT with oral and intravenous contrast enhanced showed recurrent multiple small bowel interloop abscesses were releaved. The underlying cause of recurrent interloop abscesses was mandatory to be diagnosticated. Another abdominal CT scan with rectal contrast-incoming revealed contrast extravasation in the middle sigmoid area; was interpreted as a sigmoid diverticular perforation. At emergent surgery, the patient was found to have retroperitoneal sigmoid diverticular perforation with small bowel interloop abscesses. A segmental resection of sigmoid and right transversostomy, followed by a toilette, debridement and drainage of the retroperitoneum were performed. After a week, the patient was discharged from hospital. Conclusion: Small bowel perforation is an uncommon cause of an acute abdomen. The most important pitfall would be misdiagnosing perforation elsewhere in the large bowel, as a small bowel perforation. CT scan has a high sensitivity and specificity for the detection of free air, fluids, pus and therefore for acute abdomen from gastrointestinal perforation, even if the place of perforation can not always be detected.