Perforation of the colon in the immunocompromised patient

Perforation of the colon in the immunocompromised patient is a catastrophic and usually fatal event. The immunocompromised patient, like all patients, may suffer from the more common causes of colonic perforation, including diverticulitis, chronic inflammatory bowel disease, presence of a foreign body, and trauma. There also appears to be in these patients the unusual occurrence of spontaneous perforation, particularly in patients with renal allografts or on dialysis. In a retrospective multi-hospital review, 10 cases of apparent spontaneous perforation were found. The pathogenesis is unclear, but predisposing factors include immunosuppressive medications, uremia, discrete colon ulcerations, and fecal impaction. The reported mortality rate approaches 100 percent due to delayed recognition and impaired host defense mechanisms. In our patients, mortality was 40 percent. We attribute this improved survival to prompt surgical intervention and aggressive postoperative management, including daily dialysis, parenteral hyperalimentation, broad-spectrum antibiotics, and a high index of suspicion for ongoing sepsis with early repeat exploration.