Abstract
Here we describe a rare case of hemorrhagic penetration of the diverticulum at the rectosigmoid junction presenting as intramesenteric emphysema.
An 83-year-old woman was admitted to our hospital with a sudden onset of lower abdominal pain. She had a medical history of pulmonary embolism at the age of 81 years and was taking warfarin. Mild tenderness in the lower abdomen was identified by abdominal palpation without a sign of peritoneal irritation. Results of laboratory examinations did not show any significant inflammatory response. Although abdominal computed tomography revealed no obvious free air in the abdomen, indistinguishable gas around the rectum was observed.
Hematochezia was observed 2 hours after admission. Urgent colonoscopy showed a deep recess in the rectosigmoid junction located approximately 15 cm proximal to the anal verge. The opening of the cavity was enlarged to about the same size as the colonic lumen, and mesenteric tissues were observed at the bottom of the recess. Endoscopic hemostasis was considered overwhelmingly challenging, and surgical management was chosen as the treatment. During laparotomy, a 3-cm perforation was observed on the mesenteric side of the rectosigmoid junction. Sigmoidectomy and Hartmann's procedure were performed to repair the perforation. Pathological analysis of the resected specimen suggested intramesenterically penetrating diverticulum at the rectosigmoid junction. In addition, a review of recorded imaging studies indicated that the indistinguishable gas around the rectum observed at admission was intramesenteric emphysema.
In conclusion, signs of peritoneal irritation are not always recognized in cases of intramesenteric or retroperitoneal penetration of colorectal diverticular disease. Therefore, meticulous assessment with multi-imaging modalities would be helpful to accurately diagnose such conditions and achieve earlier optimal management.
