Presentation
The patient was a known case of metastatic rectal cancer who had been undergoing surgical treatment of the primary tumor a few months before. On the recent admission, she underwent hepatic metastasectomy and ileostomy closure. On the 7th post-op day, be referred for a CT scan because of abdominal distension, tenderness, hypokalemia, and ill appearance. The WBC count was about 10000/microliter.
Patient Data
Evidence of recent hepatic metastasectomy, hematoma at the site of resection, and evidence of previous low anterior resection surgery are visible. A focus of loculated extra-luminal air is seen adjacent to a minimally edematous distal ileal loop, which likely is the site of closed ileostomy. Significant pneumoperitoneum is not present, but moderate free fluid contains several small air pockets, that raise the possibility of purulent ascites.
The red arrow depicts peri-anastomotic loculated air, and the white arrows point to the air pockets within the ascites.
Case Discussion
To exclude anastomosis leak, diagnostic drainage of the fluid was done, which shows about 4000/ microliter WBC on analysis. The patient went to the operating room, and an anastomosis leak was confirmed. The disproportionately large amount of post-op pneumoperitoneum, loculated peri-anastomotic extra-luminal air bubbles or fat stranding, and free fluid containing air pockets could be indirect signs of anastomotic leak.
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