Collagenous colitis presenting as spontaneous perforation in an 80 year old woman: Report of a Case

BACKGROUND: Perforation of the colon occurring during or shortly following colonoscopy or barium enema is a rare complication of collagenous colitis (CC). "Spontaneous" perforation in CC, in which no instigating factor is identified, is even less common, with only five cases reported to date. We report herein an additional case of spontaneous perforation in previously undiagnosed CC and review the clinical and pathological features of previously reported cases. CASE PRESENTATION: An 80 year old woman presented to the emergency department with abdominal pain preceded by approximately one month of frequent non-bloody diarrhea. Abdominal CT showed parietal thickening of the colon at the splenic flexure with pneumatosis and signs of perforation. Segmental resection was performed. Pathologic examination showed the microscopic findings typical of CC complicated by several deep ulcers and perforation. One day following discharge from hospital abdominal pain and frequent non-bloody diarrhea recurred. The patient was managed conservatively and treated with oral budesonide with resulting resolution of symptoms. CONCLUSIONS: Spontaneous perforation is a rare and serious complication of CC. All patients to date have been female. In contrast to procedure-related perforation, which favors the right colon, spontaneous perforation in CC has in all cases involved the left colon. Knowledge of spontaneous perforation as a potential complication of previously undiagnosed CC may be helpful in the evaluation and management of patients presenting with colonic perforation, especially those with risk factors for CC.