INTRODUCTION

Glucocorticoids are widely used in the treatment of many inflammatory diseases. They are responsible for several undesirable effects: osteoporosis, fluid retention and an increased susceptibility to infection (1). Digestive toxicity of glucocorticoids is dominated by peptic ulcers. Intestinal complications can take acute and serious forms, and prescribers should be aware of this (2). In our study, we present the case of a patient treated with long-term corticosteroids and who presented a sigmoid diverticulum perforation.

OBSERVATION

A 67-year-old patient with asthma and rheumatoid arthritis had been treated with corticosteroids for several years. One-week prior her admission, she presented a diffuse abdominal pain and watery diarrhoea evolving in a febrile context.

On admission to the intensive care unit, the patient was conscious, Glasgow score at 15/15, polypneic with a respiration rate at 28 cycles/min, hemodynamically unstable with a blood pressure of 70/50 mmHg, heart rate at 128 beats/min, she had a fever of 38.5°. Abdominal examination revealed impaction of the left iliac fossa. On biological assessment, she had Hb 8.7 g/l, WBC 13490/mm3, CRP 305mg/l, PT 45%. An abdomino-pelvic CT scan revealed a sigmoid abscess on diverticular sigmoiditis. The patient was taken directly to the operating room. The surgical procedure consisted of an evacuation of the sigmoid abscess, suturing of a sigmoid perforation, and placement of an outlet colostomy. Corticosteroid therapy has been stopped, and antibiotic therapy with 3rd-generation cephalosporin, metronidazole and gentamycin was started. The evolution was favourable.

Figrue 1

Peri sigmoidal abscess in perforated diverticular sigmoiditis

DISCUSSION

Diverticulitis is a prevalent gastrointestinal disorder that is associated with significant morbidity and health care costs. Complications of diverticulitis occur in approximately 12% of patients. The most common complication is phlegmon or abscess, followed by peritonitis, obstruction, and fistula (1).

Tan et al. concluded that comorbidity, steroid usage, and CRP level of > 175 mg/L are predictive of a more severe disease process (2). Patients without these risk factors could be considered for outpatient management (4).

A study conducted at the Mayo Clinic in the USA reported the results of patients treated for multiple myeloma with high-dose of corticosteroids which are considered the backbone of treatment in both the frontline and the relapsed/refractory setting (3). Its results concur with those of our case study.

Ulceration and perforation of the duodenum and stomach are well recognized complications of corticosteroid therapy. However, awareness of colon perforations related to steroid treatment is low (3).

A clear picture of acute peritonitis is an indication for emergency surgical exploration. If the patient is stable, diagnosis can be made with the aid of an abdominal CT scan. In almost all cases, management of diverticular perforation requires surgical intervention combined with antibiotic therapy targeting digestive germs (5).

The clinical signs and symptoms of bowel perforation may be obscured by the anti-inflammatory effects of steroids (3).

The presence of sepsis, peritonitis and the recourse to surgery are the main prognostic factors (4).

CONCLUSION

Glucocorticoid treatment is required in many clinical situations, and carries the risk of significant side effects.

Glucocorticoids can lead to colonic diverticular perforation with peritoneal infection, a very serious complication that can result in rapid death.

Early diagnosis and therapeutic management improve prognosis.