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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 114-115

Stercoral perforation: A rare entity


Department of Surgery, Huntington Hospital, Huntington, NY, USA

Date of Submission10-Sep-2019
Date of Decision17-Sep-2019
Date of Acceptance23-Sep-2019
Date of Web Publication27-Dec-2019

Correspondence Address:
Dr. Nisarg Mehta
374 Stockholm Street, Brooklyn, NY - 11217
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WJCS.WJCS_21_19

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  Abstract 


Stercoral perforation of the colon is a rare condition caused by the pressure necrosis resulting from hard fecaloma, which is commonly found in patients suffering from chronic constipation. Perforations are usually seen in patients afflicted with inflammatory bowel disease, tumor or malignancy, or diverticular disease. Majorly, stercoral perforation affects the elderly and often debilitated patients with a history of chronic constipation. It is a surgical emergency with high mortality, and its prognosis depends on the speed of care. Currently, the pathogenesis of the perforation is not well-defined, but it can likely be a result of long-lasting constipation. If constipation is not treated, stercoral perforation of the large bowel, including the colon and rectum may occur, which is life threatening. Due to constipation, there is an accumulation of feces resulting to large bowel distension that leads to the increase in intraluminal pressure on the walls of the colon, which may result in stercoral perforations. Here, we describe a case of a 60-year-old female who presented with acute symptoms of abdominal distention and pain.

Keywords: Chronic constipation, colon perforation, stercoral ulcer


How to cite this article:
Mehta N, Bhatt A, Zhang C. Stercoral perforation: A rare entity. World J Colorectal Surg 2019;8:114-5

How to cite this URL:
Mehta N, Bhatt A, Zhang C. Stercoral perforation: A rare entity. World J Colorectal Surg [serial online] 2019 [cited 2020 Apr 9];8:114-5. Available from: http://www.wjcs.us.com/text.asp?2019/8/4/114/274284




  Introduction Top


Stercoral perforation is a condition commonly seen in patients with history of constipation. It is believed that excessive stool burden leads to dilation of colon, leading to compromise in blood. This leads to local tissue ischemia and eventual weakening of bowel wall leading to perforation.[1]

Stercoral perforation typically occurs in the sigmoid or rectum.[2] Perforation due to fecaloma is a rare entity, but carries a high mortality rate. Untreated constipation can lead to a life-threatening complication.[2]


  Case Top


A 60-year-old female with no significant past medical or surgical history came to the emergency room with complaints of abdominal pain and constipation. The patient had a history of chronic constipation, which worsened after she went on a cruise and did not adhere to her stool softeners regimen or a high-fiber diet. Initial CT scan indicated an excess amount of stool burden in the colon. At this point, she was admitted for pain control, enema, and serial abdominal examinations. On day 2 of the admission, the patient started experiencing excessive abdominal pain. Therefore, a surgical consultant was called for evaluation. On initial abdominal examination, the patient showed peritoneal signs and a rigid abdomen. Hence, another CT scan of the abdomen and pelvis was requested. Findings suggested free air in the abdomen, likely due to perforation of the colon. Per clinical and imaging findings, we decided to take the patient for exploratory laparotomy to evaluate the pathology better and treat the perforation. On opening the peritoneum, we encountered contamination of the intraperitoneal cavity with an excess amount of fecal matter. After thoroughly examining the entire colon and irrigating the abdomen, we performed a sigmoidectomy and end colostomy. Postoperative course for the patient was uneventful.


  Discussion Top


Stercoral perforation is a life-threatening complication secondary to chronic constipation.[3] Stercoral perforation is not a common cause of colonic perforation, accounting for only 3.2% of cases.[4] It is life threatening and results in mortality in nearly one-third of the cases. The mean age of the patient is typically in the 6th decade of life.[5] With aging, the prognosis gets worse. Though mortality is about 15%–30% in emergency cases, the rate doubles in patients with comorbid conditions.[6]

Elderly people, who may be debilitated or in hospice care, and with comorbid conditions like diabetic enteropathy, hypothyroidism, or scleroderma, are more commonly associated with stercoral perforation due to increased risk of accumulation of feces from slowing gastrointestinal motility.[7] There have been several cases in the literature showing that patients on antipsychotics medications, immunosuppressive drugs, NSAIDS, and opioids are prone to fecal impaction.[7] These drugs are thought to affect colonic motility rather than the colonic wall itself, which may result in the slowing of the fecal contents causing constipation and impaction.

In patients suffering from chronic renal failure, there is a severe electrolyte imbalance, which results in fecal impaction. Fecal impaction in certain diseases such as uremia and diabetes mellitus is also seen due to electrolyte imbalance and worsening of autonomic systems. The pathogenicity of fecal impaction is often related to decreased hydration, which results in firm and adherent feces.[8] Therefore, there is increased tension on the walls of the colon, which becomes distended causing ischemia of the walls that may ulcerate and later perforation may occur at the weakened site.

Mauer et al. suggests the following four criteria in the diagnosis of stercoral perforation:[4]

  1. Perforations larger than 1 cm, which may be round or oval, and located along the antimesenteric border
  2. Accumulation of large amounts of feces, which may be exuded through the perforation
  3. Microscopic findings of ulceration and nonspecific inflammatory changes
  4. Presence of other factors like trauma, diverticular disease, and obstruction due to any malignant mass or cohesion forces.


Stercoral ulceration and perforation most commonly occur in the distal one-third of the large bowel along the anterior aspect of the rectum, the anti-mesenteric border of the rectosigmoid junction, and descending colon. These segments usually have hard formed feces, which are already devoid of water along with poorly perfused walls and increased intraluminal pressure.[8],[9]

Patients typically present an acute onset of generalized abdominal pain, history of constipation, diffuse peritonitis, and free air on plain film. On abdominal radiographic imaging, a large amount of stool may be seen collected along with the obstruction of the large bowel and pneumoperitoneum. An abdominal CT scan is the best option for diagnosis.[10]

Treatment should include surgical resection of the affected segment of the colon along with an end colostomy closure of the rectum using Hartmann's procedure.[5],[7] Furthermore, inspection for any other stercoral ulcers or fecal impactions should be conducted. Creation of proximal colostomy without resecting the diseased portion of the large bowel has led to significant higher mortality rate.[7] Intravenous antibiotics and fluid resuscitation should be part of the standard treatment. The disease is sporadic and highly fatal; therefore, at the earliest sign of fecal impaction, manual disimpaction and enemas should be tried to prevent the formation of stercoral ulcers or perforation. Laxatives should be administered to prevent the occurrence of fecal impaction, which is a major risk factor for the stercoral perforation.[11]


  Conclusion Top


Stercoral ulcer is a rare pathology. It is usually not high on the list of the differential diagnosis for a patient presenting acute abdominal pain. Therefore, a detailed history of the patient and physical exam are extremely important for correct diagnosis. Preventive measures in terms of manual disimpaction and enemas play a major role in the prevention of the stercoral ulcer formation and eventual increase in morbidity. In case of a patient presenting with a perforated stercoral ulcer, the ideal treatment would be an abdominal washout, resection of the diseased part of the colon, and end colostomy, which can be reversed at a later date.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Edden Y, Shih SS, Wexner SD. Solitary rectal ulcer syndrome and stercoral ulcers. Gastroenterol Clin North Am 2009;38:541-45.  Back to cited text no. 1
    
2.
Kwag SJ, Choi SK, Park JH, Jung EJ, Jung CY, Jung SH, et al. A stercoral perforation of the rectum. Ann Coloproctol 2013;29:77-9.  Back to cited text no. 2
    
3.
Serpell JW, Nicholls RJ. Stercoral perforation of the colon. Br J Surg 1990;77:1325-9.  Back to cited text no. 3
    
4.
Maurer CA, Renzulli P, Mazzucchelli L, Egger B, Seiler CA, Büchler MW. Use of accurate diagnostic criteria may increase incidence of stercoral perforation of the colon. Dis Colon Rectum 2000;43:991-8.  Back to cited text no. 4
    
5.
Chakravartty S, Chang A, Nunoo-Mensah J. A systematic review of stercoral perforation. Colorectal Dis 2013;15:930-5.  Back to cited text no. 5
    
6.
Søreide K, Desserud KF. Emergency surgery in the elderly: The balance between function, frailty and futility. Scand J Trauma Resusc Emerg Med 2015;23:10.  Back to cited text no. 6
    
7.
Haddad R, Bursle G, Piper B. Stercoral perforation of the sigmoid colon. ANZ J Surg 2005;75:244-6.  Back to cited text no. 7
    
8.
Sharma M, Agrawal A. Stercoral sigmoid colonic perforation with fecal peritonitis. Indian J Radiol Imaging 2010;20:126-8.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Falidas E, Mathioulakis S, Vlachos K, Archontovasilis F, Villias C. Stercoral perforation of the sigmoid colon. A case report and brief of the literature. G Chir 2017;32:368-71.  Back to cited text no. 9
    
10.
Wu CH, Wang LJ, Wong YC, Huang CC, Chen CC, Wang CJ, et al. Necrotic stercoral colitis: Importance of computed tomography findings. World J Gastroenterol 2011;17:379-84.  Back to cited text no. 10
    
11.
Wald A. Management and prevention of fecal impaction. Curr Gastroenterol Rep 2008;10:499-501.  Back to cited text no. 11
    




 

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