Presentation
Sub-total colectomy because of colon cancer, 39 °C fever on 5th post-op day with a soft abdomen on physical exam, and no leukocytosis or drain discharge
Patient Data
Evidence of sub-total colectomy and anastomosis of the ileum with the remaining sigmoid is seen. The amount of free intraperitoneal air is more than expected for the 5th post-op day. Few extra-luminal air bubbles are visible lateral to the sigmoid stump as well as omental fat stranding at mid-abdomen and moderate ascites. The surgical drain did not pass through the ascites. Considering the amount of free air, omental haziness, and extra-luminal air bubbles beside the stapler line probability of anastomosis leak was proposed.
Water-soluble contrast enema
Suspicious for contrast leakage from the sigmoid stump.
Appearances were not definitive, CT scan was performed.
Extensive leakage of the contrast via sigmoid stump defect to the peritoneal cavity depicts as well as increased intraperitoneal free air documenting the anastomosis leak.
The first three images show ileocolic anastomosis (orange arrow), sigmoid stump stapler (blue arrow), and extra-luminal air bubbles adjacent to the sigmoid stump (green arrow). In the fourth image, the white arrow points to suspected contrast extravasation. The last three images are post-contrast enema CT images showing extravasated contrast (red arrow) and the site of leakage at the sigmoid stump (yellow arrow).
Case Discussion
A disproportionate amount of free intraperitoneal air and extra-luminal air bubbles around the anastomosis may be indirect signs of anastomosis leak which, should be interpreted in the light of clinical findings.
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