Atypical presentation of postoperative faecal peritonitis in an elderly patient

A 90-year-old Caucasian man was admitted for an elective sigmoid colectomy having been recently diagnosed with colon cancer. He first presented following a 3-month history of per rectal bleeding. Flexible sigmoidoscopy demonstrated a 4 cm lesion in the proximal sigmoid colon. A biopsy confirmed adenocarcinoma. A CT colonoscopy demonstrated no further colonic lesions and staging CT demonstrated no evidence of metastasis. On postoperative day 7, patient had symptoms of nausea and vomiting. On examination, he had a tender right iliac fossa, sluggish bowel sounds but no evidence of guarding or rebound tenderness. He had no fever with a white cell count 5.8×109/L and C reactive protein 58 mg/L. Chest X-ray showed air under the diaphragm. CT abdomen and pelvis was performed on postoperative day 8 showing a moderate amount of abdominal free fluid and air beneath the anterior abdominal wall. Subsequent laparotomy revealed gangrenous anastomotic disruption and faecal peritonitis. Abdominal washout and terminal colostomy performed. Good postoperative recovery was seen.