An 89 year-old woman was admitted for several days of severe constipation, abdominal bloating and absence of flatus. She had abdominal distention with minimal abdominal tenderness on exam. Initial CT imaging demonstrated significant stool burden with prominent colonic distension extending from the cecum to the transverse colon. She required nasogastric tube decompression. Several days of an aggressive bowel regimen, scheduled enemas, and manual disimpaction were unsuccessful at relieving her constipation. A gastroenterology consult was obtained for possible colonoscopic decompression, but the procedure was ultimately deferred given the risk of colonic perforation. Frequent enemas and aggressive bowel regimen continued.
On hospital day 6, the patient complained of left groin pain and became increasingly lethargic and hypotensive. Physical examination revealed left groin crepitus extending to below the left knee. Her abdominal exam was notable for the absence of rigidity, tenderness, or guarding. Repeat CT imaging showed subcutaneous and deep thigh soft tissue emphysema extending from the retroperitoneum and likely originating from a colonic perforation. The patient and family elected not to pursue surgical intervention, opting for comfort measures. The patient expired early the next morning.
Discussion:
Bowel perforation is a surgical emergency which should be recognized and acted upon urgently. In most instances, patients present with classical signs of peritonitis, including pain, rebound tenderness, guarding, and rigidity, which facilitate a swift diagnosis. However, unusual presentations for bowel perforation may delay diagnosis. Such presentations can be masked by factors such as steroids or advanced age, or they can be characterized by remote signs away from the abdomen.
This case demonstrates a rare extraperitoneal presentation of colonic perforation with thigh tissue emphysema. Extraperitoneal signs of perforation can appear when the perforation occurs in the lower rectum, distal to the middle valve of Houston, which allows passage of air into the retroperitoneal space. Once collected in the retroperitoneum, air may travel along the fascial planes to enter the subcutaneous tissues and be detected as crepitus in the lower extremities or scrotum. In this case, it is possible that the trauma of repeated insertion of application nozzles into the rectum for enemas may have precipitated a perforation in the distal rectum.
Conclusions:
Hospitalists often serve patients at risk for bowel perforation. While classic presentations of bowel perforation include peritoneal signs, this case demonstrates the rare presentation of thigh crepitus in the absence of abdominal symptoms as the initial sign of a colonic perforation. Recognition of more obscure signs of bowel perforation is critical for prompt treatment of this surgical emergency.