Clinical diagnosis
Case 192
【Progress】
His mother agreed for his son to receive open intraperitoneal surgery for further investigation and surviving his life. Intraoperative findings showed adhesive string between diverticulum of transverse colon and gastric wall. Massive water ingestion and vomiting caused tension to the adhesive string, inducing tear of transverse colon wall.
【Discussion】
Intraperitoneal string is formed post-surgically, post-inflammatorily, post-traumatically, post-radiotherapy or congenitally. It is common that post-surgical, post traumatic or post-radiation string causes ileus, while it is rare that post-inflammatory or congenital string causes adverse effect on digestive organ (1-4). This is probably because it depends on the size or length of the string. Namely post-surgical string is longer and larger than the others. In our case, he had no past-history of receiving intraperitoneal surgery, radiation therapy or trauma. It is reported peritoneal congenital string arises at cecum to retro-peritoneal wall, at between greater omentum and lesser omentum at duodenojejunal flexure, ileocecal junction and ascending colon (1, 2). There are literatures that anomalous congenital band between right vertebral region and root of mesentery obstruct transverse colon (2, 3). However, there is no report of congenital peritoneal string at between stomach and transverse colon.
Transverse diverticulosis occurs in approximately 10 % of all colon diverticulosis (4-9). Perforated diverticulitis from transverse colon is uncommon. Colon diverticulitis causes peritonitis, peri-colon abscess and perforation. Chronically, colon diverticulitis ends up making a band which can cause bowel stricture. Meanwhile, epiploic appendagitis happens in transverse colon with the incidence of approximately 6% of all epiploic appendagitis (10). It can cause small bowel obstruction due to string formation.
In our case, it was obscure whether he had experienced transverse colitis, epiploic appendagitis or none. Intraperitoneal finding showed a colon perforation teared by string adhered between transverse colon and stomach. Our surgeon thought the string probably was formed after transverse colon diverticulitis. Irrespective of diverticulitis or appendagitis, this is the first case on perforation of transverse colon teared by string after massive intake of water.
Massive water intake provokes disturbance in electrolyte balance. Rapid decrease of sodium concentration by dilution induces to move water into brain cells (intracellular edema) appearing symptoms of headache, confusion, disorientation, nausea, vomiting, seizures, coma and death (11-15). It depends on serum sodium concentration. Symptoms appear when sodium concentration falls below 120 mEq/L (11-15). In our case, laboratory test revealed Na 126 mEq/L. Water intoxication is often found in patients with psychiatric disease with the incidence of approximately 10% in Japan (16). Most cases are patients with schizophrenia. Its etiology is uncertain. There are three dopamine routes; mesolimbic pathway; meso-cortical pathway; meso-striatal pathway: Meso-striatal pathway is related to Parkinson disease. Schizophrenia is thought to be in the state of overactivity of mesolimbic system inducing positive symptoms and/or in the state of dysfunction of meso-cortical pathway inducing negative and cognitive disorder (11-16). Anti-dopamine medicine is effective on positive symptoms but not on negative symptoms and cognitive disorder. Anti-dopamine medicine does not always elevate ADH from hypothalamus but possibly elevate secretion from brain. Meanwhile, psychiatric medicine, oxcarbazepine causes hyponatremia. Water intoxication as a side effect coming from dopamine blockers is still controversial. Our patient had mental disorder but his psychiatric medicine was unclear because of not being prescribed from our hospital.
【Summary】
We present a forty two-year-old male with perforated transverse colon after massive water uptake. Open surgery revealed that peritoneal string connected from transverse colon to stomach, teared transverse colon wall, inducing perforation. He had severe mental retardation. It is borne in mind that the peritoneal string arises after intraperitoneal surgery, radiation therapy, trauma and infection such as diverticulitis and epiploic appendagitis. Our surgeon thought the string probably was formed after transverse colon diverticulitis.
Water intoxication provokes hypo-natremia, inducing water move to brain cells, causing headache, confusion below 120 mEq/L of Na concentration in plasma (126 mEq/L in our case). Water intoxication is often found in patients in psychiatric hospital with the incidence of 10% in Japan. Most patients suffered from schizophrenia.
【References】
1.Holt RW, et al. Adhesional obstruction of the colon. Dis Colon Rectum. 1984;27:314–5.
2.Brodey PA, et al. Complete colonic obstruction secondary to adhesions. Am J Roentgenol. 1979;133:917–8.
3.Wecksell A, et al. Colonic obstruction. Adhesive remnant of infundibular-pelvic ligament constricting midascending colon. NY State J Med. 1978;78:962–4.
4.Chughtai SQ, et al. Perforated diverticulum of the transverse colon. Am J Surg 1974;127(5):508–510
5.Marchaland JP, et al. Perforated diverticulitis of the transverse colon. Ann Chir 2000;125(8):799–801
6.McClure ET, et al. Acute diverticulitis of the transverse colon with perforation: report of three cases and review of the literature. Arch Surg 1979;114(9):1068–1071
7.Wilkinson TR, et al. Perforated diverticulum of the transverse colon. Saudi J Gastroenterol 2007;13(4):194–196
8.Yamamoto M,et al. Perforated diverticulum of the transverse colon. Am J Gastroenterol 1997;92(9):1567–1569
9.El-Batrawy TM, et al. Perforated solitary diverticulitis of the transverse colon in a young woman. ANZ J Surg 2017;87(11):948–949
10.Lynn TE, et al. A clinico-pathologic study of epiploic appendages. Surg Gynecol Obstet. 1956;103:422–33
11.Hirayama T, et al Effect of chronic treatment with haloperidol on vasopressin release and behavioral changes by osmotic stimulation of the supraoptic nucleus. Life Sci. 2001 Sep 21;69(18):2147-56.
12.B. Dundas, M et al. Psychogenic polydipsia review: etiology, differential, and treatment, Current Psychiatry Reports, 2007; 9: 236–241, 2007.
13.Radojevic N, et al., “Forensic aspects of water intoxication: four case reports and review of relevant literature. Forensic Science International. 2012; 220: 1–5, 2012.
14.Verghese, C et al, “Problems and progress in the diagnosis and treatment of polydipsia and hyponatremia,” Schizophrenia Bulletin, 1996; 22:455–464.
15.De Leon, J et al. Polydipsia and water intoxication in psychiatric patients: a review of the epidemiological literature. Biological Psychiatry;1994: 408–419.
16.Naya A, et al. Psychiatric in-patients, Incidence, Psychogenic polydipsia, Hyponatremia, Water intoxication. Seisinigaku. 1983;25:519-525.(in Japanese)
2020.6.3