sigmoid colon diverticula with perforation & large intra-abdominal abscess

76 year old lady was transferred under our care with diagnosis of intestinal perforation & intra-abdominal abscess. Unfortunately patient was found to have COVID 19 pneumonia at the time of admission; complicating the matters further. The CT scan showed evidence of sigmoid colon diverticula with perforation & large intra-abdominal abscess. She was immediately operated after explaining all the risks to the family. All possible self-protection precautions against COVID were taken by the doctors and staff present in the operation theatre. A sigmoid colectomy with end colostomy (Hartman procedure) was done. Patient recovered well from both intra-abdominal sepsis and COVID-19 pneumonia after an initial stormy period needing artificial ventilation.

12 weeks later, she was evaluated for post-covid sequelae like pulmonary fibrosis. When found fit, she was re-operated to close the colostomy. She was discharged uneventfully after 12 days thus completing successfully the treatment of a dual complex problem.

Important points for emergency surgery in patients with COVID 19 infection:

1. Patients with COVID 19 infection (ranging from asymptomatic infection to frank pneumonia) have a spectrum of gastrointestinal problems too. These include simple GI problems like diarrhea, nonspecific abdominal pain, acute pancreatitis or complex issues like bowel gangrene.
2. Bowel gangrene will require an emergency surgery with due risk. The mortality is very high in such patients.
3. Diverticular perforation as seen in this patient seems more coincidental problem than any specific association with COVID-19.
4. COVID-19 pneumonia & colonic diverticular perforation are both life threatening problems individually and when together increase the risk to life more.

Important points about sigmoid diverticular perforation

1. Diverticula (grape like outpouchings) are seen in all the parts of colon; however they are most common and most concentrated in sigmoid colon.
2. Sigmoid diverticulosis is a fairly common problem in elderly patients especially ladies. However most patients do not have any complaints except constipation associated issues. Constipation and gut dysmotility are the basic problems behind formation of sigmoid colon diverticuli.
3. Perforation, bleeding, inflammatory phlegmon / luminal narrowing - stricture - & rarely malignancy are the complications associated with sigmoid diverticula.
4. Patients can have chronic complaints like abdominal pain / cramps due to low grade recurrent inflammation & fibrosis.
5. Localised perforations can be managed with antibiotics or percutaneous drainage procedure.
6. When generalized infection is present however, as in above patient he / she needs an emergency surgery. Surgery involves removal of the sigmoid colon followed by a colostomy (bringing the proximal end of intestine on the skin surface). This is done by open or laparoscopic approach depending on patient fitness, infrastructure and expertise available. The colostomy is usually closed after 12 weeks. However in a significant proportion of patients the colostomy cannot be closed due to factors like advanced age, poor general condition, significant other comorbid conditions etcetera.