Correspondence

Medical Mystery: An Unusual Complication of Colonoscopy — The Answer

N Engl J Med 2007; 357:2309-2310November 29, 2007

Article

To the Editor:

The medical mystery in the October 4 issue1 involved a 69-year-old man with left inguinoscrotal erythema, swelling, and tenderness after colonoscopy, during which he had undergone polypectomy of a moderately dysplastic tubular adenoma of the sigmoid colon. A computed tomographic (CT) scan of the patient's pelvis revealed free air in the left hemiscrotum (Figure 1AFigure 1Fournier's Gangrene Associated with Retroperitoneal Perforation of the Colon.). Further CT images of the abdomen and pelvis revealed marked diverticular disease affecting the distal colon and widespread gas in the retroperitoneal tissues, spreading along the left renal fascia (Figure 1B) and along the left psoas muscle down the left paracolic gutter, extending to the anterior abdominal wall and into the left hemiscrotum. A diagnosis of Fournier's gangrene secondary to retroperitoneal perforation of the colon during colonoscopy was made.

The patient underwent immediate exploratory laparotomy, during which necrosis of the left retroperitoneal tissues adjacent and caudal to the sigmoid colon was seen. No obvious site of colonic perforation was identified. A Hartmann's procedure was performed. At the end of this procedure, the erythema of the inguinoscrotal region that was present on physical examination at presentation had progressed to obvious gangrene of the scrotum and perineum (Figure 1C), requiring repeated radical débridement. It is unclear whether the perforation occurred at a diverticulum or the site of the polypectomy.

Marc A. Gladman, Ph.D.
Shukri K. Shami, M.S., F.R.C.S.
Queen's Hospital, Essex RM7 0AG, United Kingdom

1 References

1. 1

   Gladman MA, Shami SS. Medical mystery -- an unusual complication of colonoscopy. N Engl J Med 2007;357:1431-1431
   Full Text | Web of Science | Medline