A 58-year-old female was admitted to the department of surgery through the ED with a chief complaint of severe abdominal pain and discomfort as well as a syncopal episode thought to be related to patient's hypotensive state. She had a history of chronic pain syndrome treated with long-term sublingual 8 mg-2 mg Suboxone film therapy, current infection of hepatitis C, chronic untreated constipation, reported history of irregular heartbeat and possible history of coronary artery disease treated as outpatient with Plavix. The patient was unable to provide any family history. She currently lives with her husband and is unemployed. She stated that her only positive drug history was the suboxone. Her past surgical history revealed a partial hysterectomy, a cholecystectomy as well as an appendectomy.
On initial physical exam, the patient was found to have a diffusely tender and distended abdomen and hematochezia. She was afebrile and hypotensive with a systolic blood pressure in the 80s-90s. Her white blood count on admission was 6.5 x 109/L. Abdominopelvic CT scan revealed a bowel perforation most likely in the distal colon, ascites and fecal impaction of the large bowel (Fig. 1, Fig. 2). The initial diagnosis was perforated ischemic bowel. Emergency surgery was performed by Dr. Sylvanus Oyogoa. Intraoperatively, she was found to have extensive stool in the peritoneal cavity as well as hemoperitoneum. There was a large fecal mass located in the sigmoid colon causing pressure necrosis on surrounding tissues that had progressed to bowel perforation. Fecal material was protruding through the perforation site into the peritoneal cavity. Hartmann's procedure was used to resect the affected bowel. A splenic rupture was also noted and a splenectomy was performed (Fig. 3). The colostomy was created in the full quadrant bisecting with simple fashion and a wound VAC was placed following closure. The patient was given antibodies initially and was given Zosyn, Flagyl and Vancomycin. Post-op diagnosis was perforated bowel, fecal peritonitis, hemoperitoneum and splenic rupture. Postoperatively, she continued to show signs of sepsis as well as continual complaints of worsening abdominal pain. On POD six, a second abdominopelvic CT scan was performed and revealed increased free fluid within the abdominal cavity, increased attenuation more dependently, extraluminal oral contrast is seen in the fluid within the abdominal cavity consistent with bile leak. High-density fluid present in the left upper quadrant was suggestive of a contrast leak at the location of splenectomy (Fig. 4). This raised concern for possible venous leak and a second exploratory laparotomy with washout was performed on POD seven. Preoperative diagnosis was perforated gut with fecal peritonitis, intraabdominal abscess, and sepsis. Upon exploration of the cavity, the patient had lots of murky dusky looking fluid in the abdomen. There was no evidence of compromised bowel, she had multiple loculated abscesses within the small bowel and other areas, which were opened and washed out very gently with antibiotic solution and sterile solution. The patient tolerated the procedure well and was brought to the recovery room in stable condition. Post-op diagnosis was intraabdominal abscesses and sepsis. After re-operation, she showed steady recovery with conservative treatment.