Wu PE, Chen PJ, Su WC, Chang TK, Chen YC. Perforated sigmoid colon diverticulitis initially presenting with pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum: A case report. World J Clin Cases 2025; 13(34): 112593 [DOI: 10.12998/wjcc.v13.i34.112593]
Corresponding Author of This Article
Yen-Cheng Chen, MD, Assistant Professor, Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 80708, Taiwan. googoogi05@gmail.com
Research Domain of This Article
Surgery
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Perforated sigmoid colon diverticulitis initially presenting with pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum: A case report
Po-En Wu, Po-Jung Chen, Wei-Chih Su, Tsung-Kun Chang, Yen-Cheng Chen
Po-En Wu, Po-Jung Chen, Wei-Chih Su, Tsung-Kun Chang, Yen-Cheng Chen, Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
Po-Jung Chen, Wei-Chih Su, Tsung-Kun Chang, Yen-Cheng Chen, Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
Wei-Chih Su, Tsung-Kun Chang, Department of Surgery, Faculty of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
Yen-Cheng Chen, Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
Author contributions: Wu PE and Chen YC contributed to manuscript writing and editing, and data collection; Chen PJ, Su WC, and Chang YK contributed to conceptualization. All authors have read and approved the final manuscript.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yen-Cheng Chen, MD, Assistant Professor, Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100 Tzyou 1st Road, Kaohsiung 80708, Taiwan. googoogi05@gmail.com
Received: August 4, 2025 Revised: August 27, 2025 Accepted: November 14, 2025 Published online: December 6, 2025 Processing time: 124 Days and 18.7 Hours
Abstract
BACKGROUND
Complications occur in approximately 12% of cases of diverticulitis, with perforation occurring in up to 10% of complications. Typically, patient with perforated diverticulitis present intraperitoneally with abdominal pain and peritoneal signs. By contrast, pneumoretroperitoneum and pneumomediastinum are rare complications and lack typical symptoms, making their diagnosis difficult and often delayed, leading to increased morbidity and mortality.
CASE SUMMARY
A 66-year-old man presented with lower abdominal pain for 3 days. On examination, his vital signs were stable, and the abdomen was soft with mild distension and left lower quadrant tenderness, but no peritoneal signs were noted. Laboratory tests indicated leukocytosis and a markedly elevated C-reactive protein level. Abdominal computed tomography (CT) revealed focal wall thickening and fat stranding near the rectosigmoid junction as well as pneumoretroperitoneum, pneumomediastinum, and minor pneumoperitoneum. Suspecting hollow organ perforation, an emergent exploratory laparotomy was performed which revealed a retroperitoneal abscess with mesocolonic necrosis, likely due to perforated sigmoid diverticulitis. The patient underwent sigmoid resection with Hartmann’s procedure and retroperitoneal drainage. Follow-up CT on postoperative day 14 confirmed resolution of the free air, and the patient was discharged on postoperative day 40 with an uneventful recovery.
CONCLUSION
Pneumoretroperitoneum and pneumomediastinum are rare complications of perforated diverticulitis, often with delayed diagnosis due to the absence of peritoneal signs. CT aids detection, and timely surgical intervention is crucial.
Core Tip: This case highlights the rare but critical complications of pneumoretroperitoneum and pneumomediastinum in perforated diverticulitis, emphasizing the importance of high clinical suspicion in patients with atypical presentations. Timely computed tomography imaging and prompt surgical intervention are essential, as delayed diagnosis can lead to increased morbidity and mortality. Despite the absence of typical peritoneal signs, early detection and intervention are crucial for improving patient outcomes.
