The chicken or the egg – campylobacter‐associated rectal perforation

We present a well independent 76-year-old female with a 10-day history of profuse watery diarrhoea after consuming undercooked chicken. Preceding this, she had a 4-day history of constipation and later developed abdominal pain associated with nausea, low grade fevers and vomiting. She had no history of bowel surgery, recent travel, denied any rectal foreign body insertion, or underlying inflammatory bowel disease. On clinical examination, her observations were within normal limits, however, her abdomen was mildly distended with generalized tenderness. Laboratory tests revealed an elevated C-reactive protein (247 mg/L) with mild leucocytosis (white cell count 11 × 109/L) and electrolyte derangements. A computed tomography (CT) scan demonstrated mild proximal colitis with a 6 mm posterior rectal perforation. There were features of a presacral inflammatory phlegmon and pneumoretroperitoneum extending superiorly to the level of the aortic bifurcation (Fig. 1). The phlegmon collection was not amenable to radiological drainage. The patient was resuscitated with fluids and commenced on broad-spectrum intravenous antibiotics. A flexible sigmoidoscopy demonstrated a 2 cm full thickness posterior midline rectal perforation situated 10 cm proximal to the anal verge associated with inflamed mucosa, sloughing and purulent discharge (Fig. 2). A laparoscopy confirmed no intra-abdominal contamination and an end colostomy was fashioned to divert faecal flow. The following day, stool cultures returned positive for Campylobacter jejuni. She was discharged 5 days post-operatively with a course of oral antibiotics. A repeat CT 1 month later showed almost complete resolution of the collection (Fig. 1). Colon perforation is an uncommon sequalae of stercoral colitis that typically manifests with an insidious onset of severe pain preceded by chronic constipation.1 Ischaemic colitis is the penultimate step of perforation and presents endoscopically with mucosal oedema, ulceration and erythema.2 Our patient's atypical presentation closely resembles ischaemic colitis compounded by campylobacteriosis rather than stercoral perforation from an obstructing fecalith. Campylobacteriosis is typically a self-limiting form of infectious gastroenteritis primarily found in undercooked poultry transmitted from meat consumption or travel.3 Older adults tend to have a more severe presentation of illness with fewer symptoms,4 and are more susceptible to experience complications from the cytotoxic impact resulting in septicaemia, acute renal failure, and arrhythmias. Perforations in the rectum are rare, with most occurring in the anterior wall.5 There are scant cases of colonic perforation caused by Campylobacter spp. with most reported in the caecum of children and adults,6 albeit no reports of rectal perforation. The preceding review reported most perforations had associated colonic dilation or toxic megacolon as deleterious signs. In our case, the perforated posterior rectal wall in the absence of colonic dilatation likely reflected injury at Sudeck's point with persistent inflammation leading to ischaemia and a vulnerable point of perforation. Although stercoral colitis can present with similar features and commonly harbour organisms such as E. Coli, Enterococcus faecalis and B. fragilis, C. jejuni is rarely implicated and can behave rather differently with a more profound inflammatory response compounded by older age.7 The principles of management for elderly patients with profound diarrhoea and abdominal pain should firstly focus on resuscitation. Our case highlights the importance of prompt CT imaging and stool cultures in those with atypical presentations of colitis such as the absence of chronic constipation or faecal loading. In cases with profound gastroenteritis like Salmonella, the absence of colonic dilatation or toxic megacolon can commonly precede perforation with septic shock.8 Minimally invasive laparoscopy and endoscopic surgery can allow better visualization of the bowel quality and assess perforation to facilitate surgical judgement and guide subsequent decision making. In cases of perforation requiring surgical intervention, the fundamental aims are to mitigate potential sequalae by surgical diversion, resection, and restoration of bowel continuity. We would like to extend our acknowledgement to the colorectal team at Campbelltown Hospital. Open access publishing facilitated by Western Sydney University, as part of the Wiley - Western Sydney University agreement via the Council of Australian University Librarians. David Kadamani: Conceptualization; data curation; formal analysis; visualization; writing – original draft; writing – review and editing. Jason Diab: Supervision; validation; visualization; writing – review and editing. Michelle Smigielski: Supervision; validation; visualization; writing – review and editing.