S1674 A Rare Isolated Cecal Perforation in a Patient Presented With Ascites in the Absence of Abdominal Pain or Signs of Peritonitis: A Case Report

INTRODUCTION: Isolated cecal infarction is a rare condition. Patients typically present with abdominal pain or signs of peritonitis. We report a case of an unusual presentation of isolated cecal infarction resulting in a cecal perforation that led to a fatal outcome. CASE DESCRIPTION/METHODS: A 56-year-old man with decompensated cirrhosis presented with abdominal distension, shortness of breath, and weight gain for 1 week. Vital signs were stable. Abdominal distention was noted on physical examination, but there was no tenderness or guarding. Labs showed hemoglobin 11 g/dL, platelet count 68,000 /µL, PT 21.1 secs, INR 1.83, sodium 132 mmol/L, bicarbonate 17 mmol/L, albumin 2.2 g/dL, total bilirubin 6.5 mg/dL, AST/ALT = 52/21 IU/L, lactic acid 3.2 mmol/L. Chest x-ray was unremarkable. He presented with a typical clinical picture of large ascites needing therapeutic paracentesis, but he was admitted over the weekend due to concern about the high blood lactic acid level. On day 3 of admission, he developed hypotension and respiratory distress. Interval abdominal examination showed increased abdominal distension, tympany on percussion, no tenderness, or signs of peritonitis. His lactic acid trended up to 13 mmol/L with arterial pH 7.04, carbon dioxide 23.4, and bicarbonate 8. An upright abdominal x-ray showed subdiaphragmatic free air [Figure 1, left]; an abdominal CT confirmed the free air [Figure 1, right], and revealed cirrhosis with portal hypertension and large ascites. Exploratory laparotomy revealed isolated cecal perforation with extensive fecal contamination. Right hemicolectomy was done. Five liters of ascitic fluid was removed intraoperatively. Bacterial culture of ascitic fluid was positive for Bacteroides vulgatus and Lactobacillus rhamnosus. Blood culture grew Bacteroides stercoris. Surgical pathology reported a transmural infarction of cecum, acute serositis, and viable margins [Figures 2–3]. After the surgery, the patient died on hospital day 6. DISCUSSION: This case report describes a rare isolated cecal infarction in a cirrhotic patient who presented with a typical clinical picture of ascites without abdominal pain or signs of peritonitis. The important warning signal, in this case, was an unexplainable elevated lactic acid level on admission. Abdominal imaging should be early performed when in doubt as these patients could develop gangrenous bowel, bowel perforation, and peritonitis.Figure 1.: An upright abdominal x-ray on day 3 of admission showed subdiaphragmatic free air (left). Abdominal CT confirmed the free intraperitoneal air most likely from colonic bowel perforation (right).Figure 2.: Transmural infarction of the cecum (yellow circle) in comparison with surviving muscle nuclei (blue circle) (H&E stain, x10).Figure 3.: Neutrophils and RBCs percolate through the cecal perforation (H&E stain, x40).