A Case of Penetrated Melting Necrosis of the Colon After Establishment of Hemostasis for a Ruptured Duodenal Pseudoaneurysm

Abstract

The patient was a 59-year-old male dialysis patient with many comorbidities. He was brought into the emergency room with acute epigastric pain and shock, which were diagnosed as being caused by rupture of a pseudoaneurysm in the descending duodenum. After blood flow blockage with resuscitative endovascular balloon occlusion of the aorta (REBOA), emergency laparotomy and duodenotomy were performed and the bleeding was stopped with sutures. On the 13th postoperative day, the patient’s consciousness level and blood pressure decreased. Abdominal CT showed extensive emphysema in the sigmoid colon and rectum. Colonoscopy showed mucosal necrosis and sloughing, and emergency surgery was performed. The rectum, sigmoid colon, and ventral half of the cecum showed penetrated melting necrosis and a seaweed-like appearance. The necrotic colon was resected, a loop ileostomy was created, and drains were placed near the rectal stump and in the cecal lumen. Postoperatively, dramatic improvement of the vital signs was observed and the contrast medium from the drain was localized within the intestinal tract and fistula, with no leakage into the free peritoneal cavity. The drains were removed and the patient was discharged home. Although surgery was delayed due to poor surgical tolerance of this patient with penetrated melting necrosis of the colon, we were able to save his life by resection of the necrotic intestine, drainage, and intensive treatment.