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Colonic Perforation at CT Colonography in a Patient Without Known Colonic Disease

¹ Mayo Clinic College of Medicine, Rochester, MN 55905.
² Department of Radiology, Mayo Clinic Rochester, Mayo East 2-B, 200 First St. SW, Rochester, MN 55905.

Received October 24, 2004; accepted after revision December 21, 2004.

 
Joel G. Fletcher and C. Daniel Johnson have received funding from E-Z-EM to teach a CME course on CT colonography.

Address correspondence to J. G. Fletcher.

Keywords: CT • colonography • safety • screening

Introduction

Top Introduction Case Report Discussion References

 
CT colonography, or virtual colonoscopy, is now routinely used as a full structural examination of the colorectum following incomplete endoscopy [1] and in patients with elevated risk for complications during endoscopy or with aversion to endoscopy. CT colonography has demonstrated performance on par with optical colonoscopy in the screening of asymptomatic patients for adenomatous polyps in some hands [2] and has performed superiorly compared with nonendoscopic alternatives [3].

Optimal colonic inflation is essential to a high-quality CT colonography examination. Given the speed of image acquisition and reconstruction of MDCT scanners, patients must tolerate maximum inflation for only a few seconds, as opposed to endoscopy and barium enema, in which the colon remains inflated for much longer periods of time. Nevertheless, colonic insufflation is known to result in perforation, ranging from approximately 0.004-0.01% of cases for double contrast barium enema [4, 5] to 0.07-0.19% of cases for colonoscopy [6, 7].

To date, thousands of patients have undergone CT colonography without complications. Two cases of colonic perforation at CT have recently been reported in patients with known colonic disease [8, 9]. We report a case of perforation following CT colonography in a patient without known colonic disease.

Case Report

Top Introduction Case Report Discussion References

 
An 87-year-old man with a history of pulmonary emboli and unexplained weight loss underwent CT colonography for suspected malignancy. CT colonography was chosen over colonoscopy to maintain the patient on anticoagulation. CT colonography inflation began after 1 mg of glucagon was given subcutaneously followed by the insertion of a Flexi-Tip (E-Z-EM) enema tip with a nonlatex retention cuff. The patient complained of minimal discomfort related to the rectal tube insertion. Initially, an attempt at adequate colonic inflation was made using a PROTOCO₂L Colon Insufflator (E-Z-EM) set at 25 mm Hg threshold cutoff value, using carbon dioxide. A CT scout demonstrated inadequate colonic inflation, so the colonic insufflator was disconnected, and a nurse experienced in CT colonography inflated the patient manually, using carbon dioxide. Supine CT images with adequate inflation then were obtained. The patient was rolled into the decubitus position, and more carbon dioxide was insufflated manually before prone scanning. A repeat scout confirmed adequate colonic inflation and prone CT colonography images were acquired. While the patient complained of mild procedure-related discomfort during insufflation, he did not complain of any procedure-related discomfort after the CT colonography procedure. A staff radiologist reviewed the CT colonography data sets following scanning. Supine CT colonography images demonstrated a cecal lipoma but otherwise normal-appearing cecum and periappendiceal tissues (Fig. 1A). The prone images showed colonic perforation with resulting retroperitoneal and intraperitoneal free air (Figs. 1A, 1B, 1C, and 1D). The patient was admitted to the hospital for observation. At admission, the patient was in no distress, experiencing only vague lower abdominal pain, nonprogressive and nonradiating in nature. Physical examination revealed an afebrile patient with diffuse lower abdominal tenderness on palpation but without palpable masses. Bowel sounds were present. The patient was placed on IV antibiotics. Subsequent bowel movements were absent of blood and his abdominal pain abated. He was discharged 4 days after admission following an uneventful hospital course.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —87-year-old man on anticoagulation medication for pulmonary emboli but without known colonic disease underwent CT colonography with automatic followed by manual insufflation. Supine axial CT colonography image shows normal-appearing cecum and periappendiceal tissues without evidence of perforation following conversion to manual insufflation.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —87-year-old man on anticoagulation medication for pulmonary emboli but without known colonic disease underwent CT colonography with automatic followed by manual insufflation. Subsequent prone axial CT colonography image shows free intraperitoneal air ventral to liver surface and retroperitoneally, posterior to hepatic flexure, indicating bowel perforation.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —87-year-old man on anticoagulation medication for pulmonary emboli but without known colonic disease underwent CT colonography with automatic followed by manual insufflation. Prone axial CT colonography image shows large amount of air dissecting along pericecal tissues, implicating cecum as likely site of perforation.

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —87-year-old man on anticoagulation medication for pulmonary emboli but without known colonic disease underwent CT colonography with automatic followed by manual insufflation. Prone axial CT colonography image shows normal-appearing rectum and no evidence of rectal trauma.

Top Introduction Case Report Discussion References

Perforation as a complication of colonoscopy can be due to direct trauma by the endoscope, deep biopsy, or overinflation of the bowel. As a complication of barium enema, perforation is thought most often to result from trauma caused by insertion of the rectal tube, with overinflation during insufflation occurring less often [5].

Kozarek and Sanowski [10] studied manual versus automatic insufflation in explanted human colonic segments from 12 cadavers and found that the cecum perforated at lower pressures (mean, 120 mm Hg) compared to the sigmoid colon (mean, 202 mm Hg). The U.S. Food and Drug Administration (FDA) guidance for laparoscopic insufflators and related devices limits intraabdominal pressure to 30 mm Hg [11]. Our automatic insufflator (a PROTOCO₂L Colon Insufflator) device employs a limit of 25 mm Hg during colonic inflation and vents colonic air to the outside room when pressures exceed 50 mm Hg for 5 sec. In our case, we switched to manual insufflation because of difficulty inflating the colon. An industrial study, which recorded intracolonic pressures during manual inflation in 17 patients undergoing colonography, found that transient peak pressures during manual inflation ranged on a per-subject basis from 41 mm Hg to 148 mm Hg [12].

In our case, pericolonic air was observed in the lateral conal fascia about the cecum, indicating the cecum as the likely site of perforation. Rupture at this location may have occurred due to rupture of a diverticulum (although no right-sided diverticula were seen in this patient), or increased wall stress due to the large diameter of the colon at this location (according to Laplace's law). While mild discomfort usually is associated with uncomplicated colon inflation, our experience suggests CT colonography images should be reviewed before patient dismissal.

As CT can detect very small amounts of retroperitoneal and intraperitoneal free air, colonic perforation resulting from CT colonography examinations may result in only mild symptomatology, as observed in our case. Patients complaining of pain during or immediately following CT colonography examination for any reason should have CT images reviewed before dismissal, so that colonic perforations can be detected in a timely fashion to reduce morbidity.

References

Top Introduction Case Report Discussion References

 

1. Morrin M, Kruskal J, Farrell R, Goldberg S, McGee J, Raptopoulos V. Endoluminal CT colonography after an incomplete endoscopic colonoscopy. AJR 1999; 172:913 -918[Abstract/Free Full Text]
2. Pickhartdt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003;349 : 2191-2200[Abstract/Free Full Text]
3. Johnson CD, MacCarty RL, Welch TJ, et al. Comparison of the relative sensitivity of CT colonography and double-contrast barium enema for screen detection of colorectal polyps. Clin Gastroenterol Hepatol 2004; 2:314 -321[CrossRef][Medline]
4. Blakeborough A, Sheridan MB, Chapman AH. Complications of barium enema examinations: a survey of UK consultant radiologists, 1992 to 1994. Clin Radiol 1997;52 : 142-148[CrossRef][Medline]
5. Ghahremani GG. Iatrogenic gastrointestinal disorders. Gore RM, Levine MS, Laufer I, eds. Textbook of gastrointestinal radiology. Philadelphia, PA: Saunders Co., 1995:2583 -2599
6. Korman LY, Overholt BF, Box T, Winker CK. Perforation during colonoscopy in endoscopic ambulatory surgical centers. Gastrointest Endosc 2003; 58:554 -557[Medline]
7. Anderson ML, Pasha TM, Leighton JA. Endoscopic perforation of the colon: lessons from a 10-year study. Am J Gastroenterol 2000; 95:3418 -3422[CrossRef][Medline]
8. Coady-Fariborzian L, Angel LP, Procaccino JA. Perforated colon secondary to virtual colonoscopy: report of a case. Dis Colon Rectum 2004; 47:1247 -1249[Medline]
9. Kamar M, Portnoy O, Bar-Dayan A, et al. Actual colonic perforation in virtual colonoscopy: report of a case. Dis Colon Rectum 2004; 47:1242 -1244; discussion, 1244-1246[Medline]
10. Kozarek RA, Sanowski RA. Use of pressure release valve to prevent colonic injury during colonoscopy. Gastrointest Endosc1980; 26:139 -142[Medline]
11. U.S. Food and Drug Administration. Hysteroscopic and laparoscopic insufflators: submission guidance for a 510(K). Washington, DC: U.S. Food and Drug Administration, 1995:3 -7
12. Williams R. CO₂ hand bulb colon distention used with CT colonography [industrial scientific report]. Westbury, NY: E-Z-EM, Inc., 2002

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