[Subcutaneous emphysema as the initial symptom of perforated diverticulitis]

A 76-year-old woman with no medical history apart from hypertension was admitted to the department of Internal Medicine with rectal bleeding. A few days later she complained of severe pain in her left leg. On physical examination the leg was swollen, shiny and extremely painful to the touch. Later she developed subcutaneous emphysema of the upper leg. A CT-scan revealed perforated sigmoid diverticulitis and extensive subcutaneous and intramuscular emphysema. During surgery, a double-barrelled colostomy was raised on the transverse colon. All subcutaneous areas with emphysema were drained. During a second operation, a Hartmann resection was performed, with a distal mucous fistula on the descending colon. A few days later she died as a result of septicaemia. Subcutaneous emphysema is a rare complication of perforated diverticulitis. A lack of prospective studies on diverticulitis hampers a rational approach to this common condition in daily practice.