Published online Sep 26, 2018. doi: 10.12998/wjcc.v6.i10.384
Peer-review started: May 16, 2018
First decision: May 24, 2018
Revised: July 26, 2018
Accepted: August 26, 2018
Article in press: August 27, 2018
Published online: September 26, 2018
A 75-year-old woman arrived at our emergency department in poor clinical condition, awake, noncollaborative, oriented only in space, dehydrated, with fever (39 °C) and vomiting, oliguria and hypotension (80/50 mmHg). After 48 h, she presented an acute abdominal pain.
The diagnostic hypothesis was firstly sepsis of unknown origin.
Based on the computed tomography (CT) findings, the origin of the perforation was suspected to be gastric.
The laboratory data revealed white blood cell count of 25920 mmc, with 87% neutrophils, platelet count of 90000 mmc, hemoglobin of 10.9 gr%, C-reactive protein of 10.5 mg/dL and procalcitonin of 34.9 mg/dL.
The abdominal X-ray and CT revealed an abundant abdominopelvic peritoneal effusion, free perigastric air (along the gastrocolic ligament and under the anterior abdominal wall).
The abdomen exploration revealed a cirrhotic liver, an abundant amount of purulent intraperitoneal liquid, and a fecaloid collection in the pelvic pouch, which was buffered by the uterus. In the anterior distal part of the intraperitoneal rectum, a 2-cm long, full-thickness lesion was evident. The lesion was surrounded by a necrotic wall from which appeared a part of the blister pill pack (BPP) with the pill inside. In addition, at sigmoid level, some diverticula were filled with coprolites and the wall was rather thin. Exploratory laparotomy findings allowed us to identify the BPP initially missed on CT scan images. Review of the images revealed that it had appeared as a radiopaque intraluminal body in the high rectum, without any evidence of collection or air leakage.
The patient was submitted to an urgent exploratory laparotomy. The general clinical conditions were very bad and included hypotension and oliguria. Hence, we performed a Hartmann’s procedure and positioned three intraperitoneal drainage routes. Due to her worsening condition, the patient was transferred to the Intensive Care Unit, where she died after 10 d without any surgical complication.
As can easily be understood, the diagnosis was delayed due to the patient’s mental impairment, while the CT scan could neither reveal the presence of the BPP nor any air leakage or collection in the proximity of the rectum. Based on the CT findings, our first hypothesis was of a pneumoperitoneum caused by a gastric-duodenal perforation. Probably, as described in the literature, our difficulty in identifying the BPP had to do with the radiolucent characteristics of the BPP itself.
In some countries, a BPP is known as a “push-through pack”. Push-through packs consist of two main features: (1) the cover foil being resistant but breaking easily, so that the drug can be pressed out by easily breaking the cover foil; and (2) the semirigid formed cavity can be folded to dispense the drug by pressing it out with a thumb; in both cases, breaking the cover foil with a fingernail will make the pressing-out easier.
To the best of our knowledge, this is the first case report describing a rectal perforation caused by a BBP. In light of the exploratory laparotomy findings, we decided to review the CT scan images. The BPP initially missed on CT scan was identified as a radiopaque intraluminal body in the high rectum, without any evidence of collection or air leakage. The diagnosis of intestinal perforation following the unknown ingestion of an FB is often a difficult challenge in terms of treatment, due to its late diagnosis and a deteriorated clinical condition