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A 73-year-old woman presented to the emergency department with 2 days of crampy abdominal pain and obstipation and 2 months of fecaluria and pneumaturia. She was hemodynamically stable. Physical examination revealed hepatomegaly and left lower abdominal tenderness. She had normal liver function test results and a carcinoembryonic antigen level of 23.8 ng/mL (to convert to micrograms per liter, multiply by 1). Computed tomography of the abdomen and pelvis revealed a 9-cm, obstructed sigmoid colon mass with fistulous extensions to the bladder and small bowel and numerous metastases to the liver, peritoneum, and omentum. Pathologic analysis of an endoscopic biopsy specimen revealed a moderately differentiated colon adenocarcinoma. The patient was referred to a gastroenterologist for stent placement (Figure 1A). The night after the procedure, the patient developed generalized peritonitis, and computed tomography revealed abundant free air (Figure 1B).
Nassour I, Fang SH. Gastrointestinal Perforation. JAMA Surg. 2015;150(2):177-178. doi:10.1001/jamasurg.2014.358