Cec and You Shall Find: Cecal Perforation in a Patient with COVID-19

Excerpt

A 66-year-old man with morbid obesity (BMI 36), diabetes mellitus (HbA1c 9.4), hypertension, stage III chronic kidney disease (baseline creatinine 1.4), and obstructive sleep apnea (on home CPAP) was transferred to our emergency room due to pneumoperitoneum. Two weeks prior to transfer, he was evaluated at a community hospital emergency room for complaints of dyspnea, nausea, vomiting, abdominal pain, and diarrhea. A CT scan of abdomen and pelvis revealed diverticulosis without evidence of diverticulitis; the visualized cuts of the lower chest revealed diffuse lung infiltrates. He was diagnosed with COVID-19 by PCR testing and started on a 5-day course of dexamethasone; his abdominal pain was attributed to his viral infection. One week later, he had worsening diarrhea and abdominal pain and tested positive for Clostridioides difficile, for which oral vancomycin treatment was started. Six days into this antibiotic course, he developed sudden onset severe abdominal pain; a CT now showed extensive pneumoperitoneum without a clear source. His vital signs were within normal limits, and he was started on broad-spectrum antibiotics and transferred to Stanford Hospital for surgical management. On arrival, he had a pulse of 91, blood pressure of 161/86, respiratory rate of 17, oxygen saturation of 95% on room air, and temperature of 36.9 °C. On examination, he was obese and dyspneic while sitting upright; his abdomen was very distended but soft, with mild diffuse tenderness throughout; he had no evidence of peritonitis. His laboratory tests revealed a WBC 10 k/μL, platelets 408 k/μL, creatinine 1.4 mg/dL, and whole blood lactate 1.5 mmol/L. His outside hospital CT scan (Fig. 1) showed massive pneumoperitoneum concentrated mostly in the epigastrium. The differential diagnosis at this time included perforated peptic ulcer versus colonic perforation based on the extent of the free air. We proceeded with an exploratory laparotomy (Fig. 2).

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