Discussion:
Although sigmoidal diverticulitis is a prevalent medical-surgical
condition, the clinician may be misled in his or her diagnosis due to
the plethora of findings. Indeed, depending on the location along the
colonic tract and the pattern of acutisation, the presentation varies
from a consolable complaint to a visceral failure. We describe through
this clinical case a retropneumoperitoneum secondary to a sigmoiditis by
detailing the reasoning behind our approach. The causes of
retropneumoperitoneum to be listed are rupture of the duodenum,
perforation of the rectum, post-colonoscopy or ERCP procedure, colon
perforation, extension from pneumomediastinum or gas-containing
retroperitoneal abscess [1].
Due to a suitable anatomy combining a parietal weakness at the
mesenteric border and a loose cellulo-lympic atmopsphere, the
diverticulum can perforate and fuse into the retroperitoneum. It will
then reach the mediastinal layer by diffusing through the perineural and
perivascular sheaths and will escape in the posterior medial space
through the esophageal and aortic hiatus. This inter-compartmental
crossing is facilitated by a negative intra-thoracic pressure opposed to
a positive intra-abdominal pressure [2].
This perforative event could be accompanied by pyo-stercoral spillage
complicating this complication by inflicting purulent fuses along the
loose connective tissue of the retroperitoneum. Due to the solid nature
of the stool of the descending colon and the constipation tendency in
carriers of colonic diverticulosis, the retroperitoneal perforation
could be resumed in a gas leak. Fortunately for our patient, we faced
the most clement case. Thus, he was not deemed to require surgery at the
time. The amount of air does not correlate with the severity of the
symptoms [3], the therapeutic attitude is conditioned by the
clinical tolerance and the response to conservative treatment. Surgical
treatment should be reserved for extensive pneumoretroperitoneum that
does not respond to symptomatic treatment. During this therapeutic
window, energetic monitoring is imperative to watch for cardiac or
respiratory complications related to pericardial tompanade or
pneumothorax or suffocating cervical emphysema.