Faecopneumothorax: complication of a right paracolic gutter abscess

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We describe a 60‐year‐old man who initially presented with a 2‐week history of constipation and constant right iliac fossa pain. He was passing flatus and had no vomiting or fever. There was no history of trauma. Clinical examination showed dehydration and a tense tender right iliac fossa without any evidence of peritonitis. Digital rectal examination revealed hard impacted faeces.
An erect abdominal X‐ray (AXR) (Fig. 1a) taken 4 days prior to admission had demonstrated faecal loading. Biochemistry and full blood examination were all within normal limits. Initial treatment consisted of i.v. hydration followed by a successful manual evacuation of impacted faeces on the day of admission. In addition, he was administered a normal saline enema (1 L), apparently to good effect.
Over the next few days, he passed watery stool but had gaseous abdominal distension and persistent right iliac fossa pain. A repeat AXR (Fig. 1b) 2 days after manual faecal evacuation demonstrated some dilated loops of small bowel but the nasogastric and rectal tubes drained very little and the patient began to feel better. He was discharged on day 5 with a plan for colonoscopy in 2 weeks.
However, 10 days after discharge, he was readmitted with worsening abdominal pain and distension. He had continued to pass loose stool, and had no vomiting. Clinical examination revealed a right pleural effusion, and a tender distended right abdomen with no appreciable mass. Digital rectal examination was normal. He demonstrated signs of sepsis (T38°C, PR120, RR 28, BP 148/70). Urea, creatinine, electrolytes, liver function tests were all within normal limits. The white cell count was elevated (14.55 × 109 g/L) with a neutrophilia (11.28 × 109 g/L). He was commenced on ampicillin, cloxacillin, metronidazole and gentamicin.
A series of X‐rays (Fig. 2) and ultrasound examinations (Fig. 3a,b) demonstrated a large abdominal abscess and air fluid levels in the right chest, suggesting a hydropneumothorax or eventration of the diaphragm. He was taken to theatre and a right‐sided intercostal catheter was placed by open cut down. This evacuated a large amount of air and 2 L of faeculent fluid from the right chest (Fig. 3c). When the right faecopneumothorax was drained, the abdominal distension was noticeably reduced and the abdomen was soft to palpation. We made an assumption that there was a right peritoneal–pleural fistula.
Exploratory laparotomy revealed a sigmoid volvulus loop with the apex of the loop strongly adhered to the right lobe of the liver and the anterior abdominal wall but not adherent to the right diaphragm, indicating that he did not have a direct colopleural fistula. The right paracolic gutter and subphrenic space was filled with a large abscess cavity containing fecal fluid and gas. This was completely walled off from the rest of the abdominal cavity. The loop of sigmoid colon was perforated and was observed intra‐operatively discharging faecal matter into the right paracolic gutter collection. There were adhesions between the right diaphragm and the upper surface of the right lobe of the liver. The right chest tube was not palpable below the right diaphragm.
A sigmoid loop colectomy and a Hartmann's procedure were performed. Peritoneal lavage was done and the wound was closed. He was ventilated overnight and despite dopamine infusion and intravenous fluid and antibiotics, he died while on a ventilator within 24 h of surgery from septic shock.
Transdiaphragmatic leakage of ascites fluid through a ruptured diaphragmatic bleb or defect has been described in a patient with congenital heart defect with right heart failure and ascites,1 in patients with liver cirrhosis with ascites,2 and in patient on dialysis.
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