EP554 - Sigmoid Diverticular Perforation Mimicking Boerhaave Syndrome – A Case Report

Abstract Introduction Subcutaneous emphysema is a rare presenting complaint and can represent severe underlying pathology. Atypical occurrences of abdominal emphysema in diverticular perforations have been reported but emphysema within the thorax and neck due to sigmoid perforation is rare. We present an elderly male patient who presented with neck surgical emphysema secondary to diverticular perforation. Case presentation A 78-year-old man presented with two days history of shortness of breath and two weeks history of abdominal pain worse on coughing, newly hoarse voice, one episode of vomiting and fever. His past medical history included palliative malignant melanoma, ischaemic heart disease, asthma and chronic kidney disease. At presentation, he was tachycardic and had 95% oxygen saturation. Physical examination revealed extensive upper body subcutaneous emphysema and tender lower abdomen. Admission blood tests showed white cell count of 9.8 x 109 and C-reactive protein of 148mg/L. Urgent contrast CT scan with oral contrast excluded oesophageal perforation but demonstrated perforated sigmoid diverticulum. Due to the patient’s extensive co-morbidities and limited intra-abdominal contamination, he was managed conservatively. Discussion The patient initially had CT chest with IV contrast followed by CT with oral contrast, encompassing the abdomen and pelvis, leading to the accurate diagnosis. The presumed path of gas tracking from the perforation through the diaphragmatic hiatus contributed to the delay in reaching the correct diagnosis. In cases where patients present with subcutaneous emphysema in the upper body, particularly when CT thorax with oral contrast has ruled out oesophageal perforation, clinical suspicion for intra-abdominal causes should persist. Despite the presence of significant surgical emphysema, this patient demonstrated a favourable response to conservative measures.