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JAMA Surgery Clinical Challenge
February 2015

Gastrointestinal Perforation

Author Affiliations
  • 1Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
JAMA Surg. 2015;150(2):177-178. doi:10.1001/jamasurg.2014.358

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).