Use of accurate diagnostic criteria may increase incidence of stercoral perforation of the colon

Stercoral perforation of the sigmoid colon secondary to chronic heroin use: A case report and a review of the literature

INTRODUCTION

Stercoral perforation of the colon is a rare and life-threatening condition caused by pressure necrosis due to fecal impaction. It is commonly associated with chronic constipation, particularly in patients with neurogenic bowel disorders or prolonged opioid use. However, its occurrence in the context of chronic heroin use is rarely reported.

CASE PRESENTATION

We report the case of a 40-year-old male with a 5-year history of heroin abuse who presented with diffuse abdominal pain, vomiting, and cessation of gas and stool passage for 10 days. Physical examination revealed a distended abdomen with generalized tenderness, guarding, and a rectal examination confirmed fecal impaction. Computed tomography (CT) showed massive fecal impaction in the sigmoid colon with pneumoperitoneum, indicating perforation. The patient underwent urgent exploratory laparotomy, revealing two perforations in the sigmoid colon with extensive fecal peritonitis. A segmental resection of the sigmoid colon with colostomy was performed. Postoperatively, the patient required intensive care for septic shock but eventually recovered and was referred to an addiction treatment program.

DISCUSSION

This case highlights the serious gastrointestinal complications associated with chronic opioid use, particularly heroin. The pathophysiology involves opioid-induced inhibition of gastrointestinal motility, leading to chronic constipation, fecaloma formation, and subsequent perforation. Early recognition and prompt surgical intervention are crucial in managing stercoral perforation, which carries a high mortality rate if delayed.

CONCLUSION

This case underscores the importance of recognizing gastrointestinal risks in chronic opioid users, especially heroin, and the need for integrated care strategies to prevent severe complications like stercoral perforation.

Acute Constipation and A Stercoral Perforation: A Case Report

Stercoral perforation typically arises as a sequela of chronic constipation and can lead to bowel perforation due to fecal impaction. While uncommon, maintaining a high clinical suspicion in the appropriate setting is crucial. We present a case report involving a 52-year-old female with no history of chronic constipation, who presented with an unexplained large bowel obstruction. Subsequent extensive diagnostic workup revealed stercoral perforation, necessitating diagnostic laparoscopy and sigmoidectomy. This case underscores that while stercoral perforation can be life-threatening, clinical stability permits the use of minimally invasive techniques without compromising patient safety or health.

Stercoral perforation of the cecum: A case report

BACKGROUND

With less than 90 reported cases to date, stercoral perforation of the colon is a rare occurrence. Stercoral ulceration is thought to occur due to ischemic pressure necrosis of the bowel wall, which is caused by the presence of a stercoraceous mass. To underscore this urgent surgical situation concerning clinical presentation, surgical treatment, and results, we present the case of a 66-year-old man with a stercoral perforation.

CASE SUMMARY

A 66-year-old man with a history of hypertension, hyperlipidemia, and gout presented at the emergency department with lower abdominal pain and a low-grade fever lasting for a few hours. Abdominal computed tomography indicated a suspected bezoar (approximately 7.6 cm) in the dilated cecum, accompanied by pericolic fat stranding, mild proximal dilatation of the ileum, pneumoperitoneum, and minimal ascites. Intraoperatively, feculent peritonitis with isolated cecal perforation were observed. Consequently, a right hemicolectomy with peritoneal lavage was performed. A histopathological examination supported the intraoperative findings.

CONCLUSION

In stercoral perforations, a diagnosis should be diligently pursued, especially in older adults, and prompt surgical intervention should be implemented.

Stercoral colitis in the emergency department: a review of the literature

BACKGROUND

Stercoral colitis (SC) is a rare but potentially life-threatening inflammatory colitis caused by the accumulation of impacted fecal material. Despite reported associations with bowel perforation and high mortality rates, stercoral colitis remains a poorly defined and underrecognized diagnosis in the emergency department (ED).

OBJECTIVE OF THE REVIEW

This review aims to summarize and synthesize existing literature on SC to guide its recognition and management in the ED.

DISCUSSION

SC primarily occurs in elderly or bedbound patients with chronic constipation; however, it does occur in younger patients with comorbidities at increased risk for fecal impaction. Patients may present acutely with abdominal pain and distension, but clinical presentation is often nonspecific and varied, and there are no established diagnostic criteria for SC to date. CT is therefore crucial for diagnosis, revealing key findings such as fecaloma, colonic dilatation, and fat stranding. Treatment depends on severity of illness, ranging from manual disimpaction and other conservative measures for most cases, to surgical intervention for complicated cases, such as stercoral perforation.

CONCLUSIONS

SC can be a challenging diagnosis in the ED, often requiring multidisciplinary collaboration. Timely recognition and appropriate treatment are essential to reduce morbidity and mortality associated with this condition. Further research is needed to establish diagnostic criteria and clear management algorithms.

Rectal stercoral perforation: an uncommon anatomical localization of a rare surgical emergency

A stercoral rectal perforation is an uncommon cause of acute abdominal pain with only limited cases documented in medical literature. Timely and accurate imaging is essential when this condition is suspected, and immediate surgical intervention is imperative upon confirming the diagnosis of bowel perforation. Usually, the definitive diagnosis of a stercoral rectal perforation is established intraoperatively and a Hartmann procedure with (temporary) end colostomy is performed. In this case report, we present our first-hand experience in managing a stercoral rectal perforation, highlighting the importance of early diagnosis and rapid surgical intervention to achieve favorable outcomes.

Stercoral colitis: CT imaging findings and clinical risk factors

PURPOSE

To describe and update stercoral colitis clinical risk factors, relative frequency, location, and CT imaging features correlated with surgical and pathological results.

METHODS

CT reports over a 5-year period (05/2017-05/2022) at a single medical center were searched. Main inclusion criteria were luminal distention with formed stool, wall thickening, and surrounding inflammation. Positive cases were graded as mild (early or developing stercoral colitis) versus moderate-to-severe based on CT findings. Medical records were reviewed for risk factors and outcome data in moderate-to-severe cases. P-values were tabulated for comparison.

RESULTS

545 total cases (71 (60, 82) years, 278 males) were identified on CT, including 452 mild (82.9%) and 93 moderate-to-severe cases (17%, 67 (55, 79) years, 48 females). Twenty cases showed evidence of perforation (3.7% total cohort, 22% moderate-to-severe cohort). Diagnosis as an incidental finding was frequent (46.0% of mild cases). Most cases involved the rectum (97.6% of mild cohort and 69% of moderate-to-severe cohort). The sigmoid was involved in 31% of moderate-to-severe cases, but 95% of the perforated subcohort (19/20, 13/20 without rectal involvement). Among the moderate-to-severe cohort, perforation was associated with slightly increased wall thickness (6.4 vs. 5.7 mm, p = 0.03), opioid use (50 vs. 23%, p = 0.04), and disease-specific mortality (11 vs. 0%, p =0.04). Perforation was less associated with major neurocognitive disorders (20 vs. 60%, p = 0.003), institutionalized status (5 vs. 38%, p = 0.005), and a prescribed bowel regimen (30 vs. 63%, p = 0.01).

CONCLUSION

Stercoral colitis may be under-reported. Perforation tends to favor sigmoid involvement and a less traditional patient cohort.

Stercoral Ulcer Presenting in a Patient with Cauda Equina Syndrome Secondary to Postoperative Epidural Hematoma

Chronic constipation can lead to fecal impaction in the large bowel, which can cause pressure necrosis followed by perforation, known as a stercoral ulcer. In extensive posterior thoracolumbar surgery, a long operation time, large blood loss, and perioperative narcotic use may aggravate constipation. Moreover, sacral root palsy due to cauda equina syndrome (CES) can lead to the deterioration of fecal impaction. This report describes the case of a 77-year-old woman with CES who presented with saddle anesthesia, neurogenic bladder, bowel incontinence, and paraplegia. Five days prior, she had undergone extended posterior lumbar interbody fusion from L1 to L5. Lumbar magnetic resonance imaging (MRI) showed an extended epidural hematoma. After urgent neural decompression, she gradually recovered from the saddle anesthesia, leg pain, and paraplegia over 3 weeks. Thereafter, the patient suddenly developed massive hematochezia and hemorrhagic shock. Urgent colonoscopy was performed, and a stercoral ulcer in the sigmoid colon was diagnosed. After 4 weeks of intensive care for hemorrhagic shock, pneumonia, and systemic sepsis, the patient was transferred to a general ward for intensive rehabilitation. One year after the operation, she was able to walk with assistance, and her urinary and bowel incontinence completely recovered. Chronic constipation, a common clinical problem, can sometimes cause relatively obscure but potentially life-threatening complications such as stercoral ulceration. Possible factors including advanced age, extensive spinal surgeries, prolonged operation time, significant blood loss, perioperative narcotic use, and the presence of spinal cord injury might contribute to the development of this condition. It highlights the importance of recognizing the potential development of stercoral ulcers in patients with CES and emphasizes the need for prompt diagnosis and management to avert catastrophic complications.

Fecal Impaction and Nonperforated Stercoral Colitis: Red Flags for Poor Outcomes

Fecal impaction and stercoral colitis are common, yet little research has been performed on the associated mortality risk. We performed a retrospective cohort study of 970 hospital encounters representing 885 unique patients in which fecal impaction or stercoral colitis was identified in CT reports. Among the 535 patients with fecal impaction, 13.3% died or were discharged to hospice, compared to 13.1% among the 428 patients with nonperforated stercoral colitis (p = 0.93). Of the seven patients with perforation, five died or were discharged to hospice. The risk of death or discharge to hospice for patients with fecal impaction or nonperforated stercoral colitis aged 18-49 was 2.9% and rose approximately 4% each decade thereafter to 21.9% for patients 90 and older (p< 0.001). Patients with a body mass index of 25-30 had an 8.1% risk of death or discharge to hospice, compared to 23.4% for those with a BMI < 18.5 (p< 0.001). Patients with at least one ICD-10 code for dementia, paralysis/neuromuscular disease, or malnutrition/failure to thrive had a risk of death or discharge to hospice of 21.6%, compared to 1.9% among patients with none of these risk factors (p< 0.001). ICD-10 codes for sepsis were associated with 90.0% of the deaths and 44.3% of the discharges to hospice. Patients diagnosed in less than three hours had a risk of death or discharge to hospice of 8.0%, compared to a risk of 20.1% for those diagnosed in ≥ 12 hours (p< 0.001).

Stercoral Perforation in the Setting of Chronic Antipsychotic Use: A Case Report

Stercoral perforation is a rare form of colonic perforation with limited reports in the literature, accounting for less than 140 documented cases. This complication occurs due to increased intraluminal pressure created by fecal impaction, ultimately causing colonic ulceration and necrosis. It is most often seen in elderly or debilitated patients with chronic constipation. The long-term use of drugs or medications with side effects of chronic constipation such as opioids, antispasmodics, tricyclic antidepressants, and calcium channel blockers have been implicated in these cases. Here we present a case of stercoral perforation in a patient with short-term opioid use following an orthopedic procedure, but more likely complicated by long-term use of antipsychotics and antidepressants.

Chronic constipation that resulted in fecal impaction and colon perforation: A case report

RATIONALE

Gastrointestinal (GI) motility disorders represent a set of variable presentations caused by an abnormal functioning enteric neuromusculature. Any part of the GI tract can be affected, and depending on the organ involved, the patient presentation will differ.

PATIENT CONCERNS

A 26-years old female who had a history of laparoscopic Heller myotomy 15 years ago for progressive dysphagia. She presented with peritonitis and sigmoid colon perforation secondary to severe chronic constipation. Later after undergoing Hartman procedure, she continued to have significant constipation. In addition, she reported progressive dysphagia and regurgitation to both solids and liquids.

DIAGNOSIS

An esophageal manometry revealed Achalasia type 3, and stomach motility nuclear study showed mild delay in gastric emptying.

INTERVENTIONS

Initially, Hartmann procedure was performed. Afterward, we performed a reversal of Hartman, robotic redo of Heller myotomy, and Dor fundoplication was performed.

OUTCOMES

The patient had an uneventful postoperative course and was discharged in good condition.

LESSONS

Our case highlights an unusual presentation of GI motility disorder resulting in peritonitis from sigmoid colon perforation. Early recognition and prompt treatment of GI motility disorders are essential to avoid severe complications.

Massive Rectal Hemorrhage From a Stercoral Ulcer

Massive lower gastrointestinal (GI) bleeding from stercoral ulcers is exceedingly rare. We report a case of a middle-aged man who presented with progressively deteriorating neurologic function with constipation and subsequent massive GI bleeding per rectum. While an uncommon cause of GI bleeding, such patients require rapid resuscitation and timely diagnosis of these ulcers since the usual management of such cases will be futile and harmful due to potentially inappropriate surgical bowel resection.

Surgical treatment of acute aortic dissection in a patient with SLE and prior antiphospholipid syndrome on therapy for over 30 years: a case report

BACKGROUND

In patients with systemic lupus erythematosus (SLE), lengthy treatment and long-term steroid use are the main risk factors for developing aortic aneurysms or aortic dissections. In patients with cardiac tamponade, hemodynamic collapse may lead to acute renal and hepatic failure.

CASE PRESENTATION

We report the successful treatment of a 55-year-old woman with SLE since the age of 21. She suddenly felt chest pain approximately 2 weeks before developing fever and vomiting and was admitted to our hospital. Initially, she had severe liver dysfunction and was admitted to the hepatology department, where treatment for fulminant hepatitis was initiated. However, computed tomography (CT) showed an acute aortic dissection (DeBakey type II) and severe bloody pericardial effusion. Therefore, we performed emergency pericardial drainage. Plasma exchange therapy was initiated as emergency aortic surgery was deemed impossible due to impaired liver function tests and coagulation. Ten days later, the patient developed peritonitis due to small bowel perforation, and laparotomy was performed for abscess drainage and perforation closure. She had received steroid pulse therapy at the age of 21. At 40 years of age, she developed deep vein thrombosis due to antiphospholipid antibodies and was prescribed prednisolone. She was ambulatory at 3 months after the onset of acute aortic dissection, and CT revealed a rapidly enlarging true aneurysm in the distal arch. We performed elective aortic surgery. Although there were no antiphospholipid antibodies, surgery could have led to a devastating antiphospholipid syndrome. Therefore, we decided to treat the patient with triple therapy. Methylprednisolone was intravenously administered intraoperatively and at 1 day postoperatively. The patient was discharged without complications after returning to her usual oral prednisolone regimen.

CONCLUSIONS

The patient described herein had a systemic circulatory failure due to cardiac tamponade, accompanied by liver failure. This condition is a significant cause of death in patients with aortic dissection-associated SLE and is extremely dangerous. However, multi-specialty intervention helped the patient recover, and she has been attending the outpatient clinic. Aortic surgery requiring hypothermia in SLE patients with antiphospholipid syndrome and a history of thrombocytopenia or thrombosis requires a multi-disciplinary treatment team, including cardiac surgeons and medical experts.

Laparoscopic Management of Spontaneous Colonic Perforation: A Single Institution Study of 52 Patients

BACKGROUND

Spontaneous colonic perforation (SCP) is associated with an devastating result. The use of laparoscopy for SCP remains controversial. This study aimed to compare the postoperative outcomes of patients who received either laparoscopic or open surgery and to evaluate the efficacy of laparoscopic surgery and the risk factors affecting prognosis.

PATIENTS AND METHODS

A retrospective study of patients who underwent surgery for SCP from January 2005 to December 2020 was performed. Demographic data, intraoperative variables, length of stay, and surgical complications were retrieved.

RESULTS

A total of 52 patients were postoperatively diagnosed with SCP. Thirty (57.69%) procedures were performed using laparoscopic surgery (group A) and 22 (42.31%) were performed using open surgery (group B). There were no significant differences between groups A and B in terms of age, sex, chronic concomitant disease, chronic constipation, incentives, imaging findings, preoperative diagnosis, American Society of Anesthesiologists (ASA) score, Mannheim Peritonitis Index (MPI), operation time, days to resumption of liquids, site of perforation, surgical procedures, or types of perforation (P>0.05). The incidence of wound infection in group A was significantly lower than that in group B (P<0.05), but there was no significant difference in the incidence of abdominal abscess between the 2 groups (P>0.05). Significant differences were found in days to start walking and days to resumption of solids between the 2 groups (P<0.05). Group B had a longer length of hospital stay than group A (P<0.05). After multivariate analysis, the independent variables associated with worse perioperative complications were an age of 65 years and older, an ASA score of ≥3, and an MPI of >26.

CONCLUSIONS

The prognosis of SCP is poor. The operation should follow principles that are simple, rapid, and effective. If there are no contraindications, laparoscopy may be the preferred method. Hartmann procedure is a promising surgical strategy. The age, ASA score, and MPI may indicate the severity and prognosis of SCP.

Prognostic Factors of Patients with Stercoral Perforation of the Colon

Background/Aims

The incidence of stercoral perforation of the colon (SPC) is expected to rise, given the increased life expectancy and the aging population. On the other hand, the prognostic factors of mortality after surgery for SPC remain unclear. This study examined the prognostic factors of patients with SPC after surgery.

Methods

The medical records of 145 patients who underwent surgery for colonic perforation between April 2010 and May 2019 were reviewed retrospectively. In 145 patients, 22 patients who underwent SPC surgery were categorized into the following two groups according to in-hospital survival after surgery: alive (group A, n=15) and dead (group B, n=7).

Results

In all enrolled patients, the mean age was 75.7±9.0 years, with a female predominance (female patients, n=19, 86.4%). Sixteen patients (72.7%) had chronic constipation with medications, and five patients (22.7%) were bedridden. The rate of preoperative bedridden status was significantly higher in group B than group A (6.7% vs. 57.1%; p=0.021). Univariate analysis revealed immobility, a sequential organ failure assessment (SOFA) score, and lactate levels of more than 2.0 mmol/L to be factors associated with increased mortality rates in the postoperative period. Multivariate analysis revealed abnormal lactate levels to be the only factor related to mortality (hazard ratio 16.50, 95% CI 1.48-183.07, p=0.022).

Conclusions

Preoperative abnormal serum lactate levels may be a risk factor for mortality after surgery in patients with stercoral perforation. Further research will be needed to identify the postoperative prognostic SPC factors.

Stercoral colitis due to massive fecal impaction: a case report and literature review

Stercoral colitis is a rare inflammatory condition involving the large bowel wall secondary to fecal impaction. Stercoral colitis has a clinical course ranging from non-complicated fecaloid impaction to colonic perforation. This case report aims to give a brief review of this condition and discuss its imaging findings.

CASE PRESENTATION

We herein report a case 74-year-old female who presented with abdominal pain, abdominal distension, and the absence of gas-feces discharge for a few days. The patient had a one-year history of chronic constipation and recent femoral neck fracture surgery. Physical examination shows abdominal distension with slight tenderness. Abdominal radiographs demonstrated bowel distention and fecal material in the colorectal regions. Computed tomography (CT) images demonstrated abundant fecal material with massive dilatation in the rectosigmoid colon, focal mural thickening, subtle pericolic fat stranding, and minimal free fluid in the abdominal and pelvic cavities. Based on these findings, the diagnosis of stercoral colitis was made. The patient was treated conservatively and eventually discharged with a good health condition.

CONCLUSION

Stercoral colitis seems to be more common in elderly patients with comorbid diseases. Chronic constipation causing fecal impaction is a major risk factor. CT scan is the most helpful imaging modality for the diagnosis of stercoral colitis. CT findings that should prompt the radiologist to consider this diagnosis include colonic dilatation containing impacted feces, mural thickening, and pericolic fat stranding. If the fecal impaction is not promptly relieved, life-threatening complications such as colonic perforation can occur.

Rare but relevant: a systematic review of stercoral perforation

BACKGROUND/AIMS

Knowledge of the aetiologies of large bowel perforation are fundamental to its management. Stercoral perforation is a rare cause associated with high mortality. Owing to the paucity of coverage of this condition in the literature, this review raises awareness of stercoral perforation among clinicians.

METHOD

A literature search of PubMed, Embase, MEDLINE, CINAHL, Ovid and Cochrane was performed. Key search terms included 'stercoral, perforation', 'perforated', 'perforat*' and 'stercoral perforation'. Only literature published between December 2011 and July 2020 was included to avoid duplication.

RESULTS

Twenty-nine papers were obtained giving an overall cohort of 58 patients. The median age was 58 years (range 2-83 years) and 72.4% (n=42) were female. Constipation was reported in 69% (n=40) and 20.7% (n=12) reported chronic opioid use. A computed tomography scan was performed in 94.8% (n=55) of cases and typically a Hartmann's procedure (n=40, 72.2%) was performed. The mortality rate was 17.2% (n=10).

CONCLUSIONS

The median age of patients with stercoral perforation has decreased from that found in previous studies and the mortality rate has improved. Chronic opioid users have also emerged as an important cohort. Early recognition, diligent decision making and focused perioperative care form the backbone of the definitive management of stercoral perforation.

Stercoral re-perforation after colostomy takedown: a case report

Background

Stercoral perforation (SP) is a rare surgical condition that is associated with high morbidity and mortality. Most of these patients undergo emergent surgery, including colostomy, and some undergo colostomy takedown after recovery. Stercoral re-perforation after colostomy takedown followed by colostomy for SP has not yet been reported.

Case presentation

A 79-year-old woman presented with abdominal pain for one day. Abdominal-pelvis computed tomography revealed pneumoperitoneum with diffuse mesenteric fat haziness of the left abdomen. During laparoscopic exploration, a 3-cm-sized perforated site was found at the sigmoid-descending colon, with fecal material and reactive fluid outside the colon. Loop colostomy formation was performed, and a takedown was completed after 3 months. Two years 4 months after the initial procedure, the patient was re-admitted to our hospital with abdominal pain. She underwent a second laparoscopic colostomy formation and was discharged, although the postoperative clinical course was poorer than that after the first surgery.

Conclusions

This case of stercoral re-perforation after colostomy takedown followed by colostomy formation for SP has important clinical implications and can be a reference for physicians. When the first colostomy formation was performed for SP, the decision on performance of a colostomy takedown should be made after carefully considering several factors.

A case of colonic obstruction combined with ischemic colitis

CT scan of the abdomen showing a large amount of feces in the anterior descending recto-sigmoid colon with wall thickening (red arrow) and surrounding fat stranding (yellow arrow) suggestive of stercoral colitis.

Stercoral perforation of the colon: a mortal consequence of chronic constipation in the elderly (a case report)

The stercoral perforation is a mortal condition. It affects elderly patients who have a long history of chronic and severe constipation as well as constitutes a surgical emergency whose prognosis, often grim, depends on the early diagnosis and treatment. We report the case of a stercoral colon perforation which occurred in an 89-year-old patient. The clinical symptomatology was that of an acute peritonitis evolving for four days. The diagnosis was only made intraoperatively and the surgical gesture was a resection of the involved left colon segment and Bouilly Volkmann colostomy. The consequences were unfortunately marked by a resistant septic shock resulting in the death of the patient on the 1st postoperative day. The diagnosis of stercoral colon perforation, which is often difficult and delayed, must be known by all physicians who manage an increasingly older patient population.

Stercoral Colitis in a Patient With Pediatric-Onset Systemic Lupus Erythematosus: Case Analysis and Review of the Literature

Systemic lupus erythematosus (SLE) is an autoantibody-related disease that affects multiple organs. Stercoral colitis (SC) is a rare type of inflammatory colitis with a high mortality rate. Here, we report the first case of pediatric-onset lupus in a case complicated by stercoral colitis. We also conducted a literature review of patients with SC under 30 years old to provide useful clues for rapid diagnosis at a young age. A 28-year-old female with a history of lupus and neuropsychiatric SLE was admitted with severe abdominal pain. She was found to have stercoral colitis during surgery. Two years later, the patient underwent Hartman's operation due to ischemia of the colon. In addition, 10 patients younger than 30 years old with a diagnosis of SC were analyzed based on clinical presentation, physical examination, laboratory exam, imaging and treatment. All cases had a favorable outcome without mortality. Stercoral colitis is a rare but lethal complication, emphasizing the importance of a multidisciplinary approach. Differential diagnosis should include stercoral colitis for patients with SLE developing unexplained sharp abdominal pain.

Idiopathic spontaneous cecal perforation: A rare pathology with high mortality

Introduction

Spontaneous perforation of the colon (SPC) is a rare disease characterized by sudden perforation of a clinically healthy colon in the absence of underlying disease or trauma. The aim of reporting this case is to highlight this surgical emergency in terms of clinical presentations, surgical management and outcomes.

Presentation of case

A 68 year-old male with history of diabetes mellitus, hypertension and chronic constipation on daily laxatives presented to the emergency department with a diffuse abdominal pain and distention for 4 days associated with vomiting and absence of defecation where he was prescribed phosphate rectal enemas. Patient was in sepsis with generalized abdominal tenderness and distention. Intraoperative findings of feculent peritonitis with isolated cecal perforation was identified, for which a right hemicolectomy with end ileostomy was performed.

Discussion

The first case was described in a woman presented with spontaneous rectum rupture by Brodie in 1827, with a less than 100 cases being reported in literature. In 1984, spontaneous perforations were classified into either "stercoral" or "idiopathic" perforations. More than 60% of colonic perforations were reported in the sigmoid or at the recto-sigmoid junction, mainly at the anti-mesenteric border, making spontaneous cecal perforation a very uncommon condition. Cecal perforation is associated with high mortality in the range of 30%-72%.

Conclusion

The outcome of SPC depends on multiple factors like onset of perforation, peritoneal contamination, and time of intervention. Regardless the surgical technique, early detection and surgical management are the main strategies associated with improving the outcomes.

Stercoral Perforation of Sigmoid Colon in Systemic Lupus Erythematosus: A Rare Cause of Peritonitis

Stercoral perforation (SP) is a rare cause of peritonitis. It is caused by pressure necrosis of the colonic wall by fecaloma. SP is a lethal condition that is associated with high morbidity and mortality, therefore early diagnosis and treatment are of paramount importance. Herein, we describe a case of SP in a systemic lupus erythematosus (SLE) patient.

A 44-year-old female, known case of SLE, presented with severe abdominal pain, fever, and hypotension. CT scan showed features of perforated sigmoid. The patient underwent exploratory laparotomy which revealed perforation of sigmoid, fecalomas in the peritoneal cavity, and colon loaded with fecal matter. The patient underwent Hartmann's operation with successful control of her intra-abdominal sepsis. Her postoperative course was complicated by SLE flare and wound dehiscence which was probably due to long term steroid use.

Even though SP is rare, it carries a worse prognosis especially if the patients are immunocompromised. The key to successfully manage such cases is early diagnosis, aggressive resuscitation, antibiotics, and prompt surgical intervention. A multidisciplinary approach is often helpful in such cases.

Pelvic Rectal Stercoral Perforation Resulting in Diffuse Pneumatosis

An 83-year-old woman with oral corticosteroid use for chronic autoimmune conditions presented with abdominal pain and constipation for the previous seven days. CT of the abdomen and pelvis revealed a large fecaloma with diffuse pneumatosis involving the retroperitoneum, subcutaneous tissue, and mediastinum. An emergent exploratory laparotomy revealed perforation of the rectum below the peritoneal reflection into the retroperitoneum. An end-colostomy with Hartmann's operation was then performed intra-operatively. Despite operative treatment complicated by prolonged intubation, the patient succumbed to multiorgan failure and expired.

Spontaneous colonic perforation in adults: Evaluation of a pooled case series

Spontaneous colonic perforation in adults (SCPA) is rare but important. Its clinicopathological features and outcomes remain unclear. Therefore, the aim of the current study was to explore and investigate the clinicopathological characteristics, clinical outcomes and potential risk factors for patients with SCPA. Data of seven patients with SCPA treated in our hospitals from January 2008 to December 2017, and 221 cases from research databases before 2018 were retrospectively analyzed. The description of SCPA included stercoral perforation of the colon (SPC), idiopathic perforation of the colon (IPC) and spontaneous colonic perforation (SCP) in the study. All SCPA patients presented with unexplained abdominal pain and peritonitis. The median age was 62.5 years. The definite diagnosis preoperatively was 20.6%. The commonest lesion location was sigmoid colon and Hartmann's operation accounted for 59.3%. Histopathology of stercoral perforation (HSP) and histopathology of idiopathic perforation (HIP) were two histopathological findings. Postoperative complication was 67.7% and mortality was 31.1%. Univariate and multivariate analyses showed that chronic constipation was an independent risk factor for histopathological features (p ≤ 0.001, p = 0.005). Age of patients was associated with both postoperative complication (p = 0.012, p = 0.044) and mortality (p = 0.013, p = 0.034). Univariate analysis showed that HSP was associated with postoperative complication (p = 0.015). Our findings from the analysis pertaining to SCPA confirm those from previous studies, supporting the SCPA, as a uniform description, is an infrequent and life-threatening disease requiring early surgical intervention. We found that the elderly with chronic constipation was a high-risk category and those with HIP had a more favorable outcome than that of patients with HSP.

Successful multi-stage treatment of stoma limb perforation following Hartmann's operation report a case

Background

Stoma-related complications are not rare, whereas the spontaneous perforation of the stoma limb is relatively rare. Herein, we report a case of stoma limb perforation which occurred after Hartmann’s operation.

Case presentation

A 50-year-old Japanese man presented to our Hospital with acute and severe abdominal pain. Abdominal computed tomography (CT) scan revealed that an abscess with free air was formed around the sigmoid colon. We performed Hartmann’s operation, whereas he experienced redness, purulent discharge, and swelling around the colostomy at 10 days postoperatively. The contrast-enhanced CT scan of the abdomen revealed an abscess formation with air around the colostomy. He was diagnosed with an abdominal wall abscess due to perforation of the stoma limb.

After the drainage, his symptoms were ameliorated by oral analgesics, anti-inflammatory drugs, and prophylactic antibiotic. Four months after the first operation, we performed a closedown of the sigmoid colostomy and fistula resection. The patient’s postoperative course was uneventful, and he was discharged 14 days later.

Conclusions

This case depicts rare complications of Hartmann’s operation. Operation is usually performed in patients with stoma limb perforation. However, if they are stable and the abscess is located in their abdominal wall, they may be treated successfully using a multi-stage approach of local drainage toward the stoma wall followed by stoma closure.

Differentiation between stercoral perforation and colorectal cancer perforation

OBJECTIVE

To determine the computed tomography (CT) signs associated with stercoral perforation and colorectal cancer perforation.

MATERIALS AND METHODS

From May 2003 to Feb. 2015, all surgically and pathologically confirmed patients with stercoral perforation (n=8, mean age 68.3 years) or colon cancer perforation (n=11, mean age 66.3 years) were retrospectively reviewed by two board-certified radiologists blinded to the proven diagnosis. The following CT findings were evaluated and recorded for each patient: wall thickness of the distal colon adjacent to perforation site, pattern of the colon wall thickening and enhancement, length of the thickened bowel wall, presence of fecaloma, degree of proximal colon dilatation, and pericolonic inflammation or presence of pericolonic abscess, and number of enlarged pericolonic lymph nodes. These findings were correlated with the pathologic diagnosis.

RESULTS

The mean thickness of the distal colonic wall adjacent to the perforation site was 13.6 mm in patients with colorectal cancer perforation and 5.1 mm with stercoral perforation, which was statistically different. There was a significant correlation between colorectal cancer perforation and eccentric wall thickening (p<0.01). CT findings of layered enhancing wall thickening (p<0.01) and the presence of fecaloma in the proximal colon (p<0.01) were significant findings for stercoral perforation. Patients with colorectal cancer displayed more pericolonic lymph nodes (mean 2.27, p<0.05).

CONCLUSION

Fecaloma in the proximal colon and layered enhancing wall thickening adjacent to perforation site are likely due to stercoral perforation. Eccentric bowel wall thickening at the distal portion of the perforation site with many enlarged pericolonic lymph nodes is most likely due to colorectal cancer perforation.

Abdominal compartment syndrome secondary to megarectum and megasigmoid

A 31-year-old male patient with chronic constipation of unknown aetiology presented emergently with worsening nausea, vomiting and abdominal distension of one week duration. On examination, his abdomen was distended with minimal tenderness. A plain film of the abdomen demonstrated severe faecal loading. The patient was haemodynamically unstable on admission and appeared sick. An urgent CT abdomen and pelvis was conducted showing extensive rectal dilatation and associated proximal colonic stercoral perforation. The patient proceeded straight to theatre for laparotomy as his general condition was deteriorating rapidly. On transfer to the operating table, the patient suffered cardiopulmonary arrest. Resuscitation was immediately commenced. Abdominal compartment syndrome was suspected. Cardiac output was re-established following a midline laparotomy which acted relieve the abdominal pressure. The rectosigmoid faecal content was decompressed via an enterotomy. The perforated segment of transverse colon was resected and an end colostomy fashioned. A year later, the continuity of the bowel was re-established.

Hemospray as the Initial Treatment of a Lower Gastrointestinal Bleed Resulting from Stercoral Ulceration

Stercoral ulceration, an uncommon complication of constipation and fecal impaction, can present as a significant lower gastrointestinal bleed. Endoscopic management of this complication is rarely described in the literature. We describe the first documented case of an individual with massive hematochezia in the setting of stercoral ulceration being managed with Hemospray (Cook Medical, Bloomington, Indiana).

Stercoral perforation proximal to the stapled anastomosis after low anterior resection with an intraluminal device

Stercoral perforation of the colon is a rare phenomenon and a potential life-threatening condition requiring acute intervention. A little more than 200 cases have been described to date. The mechanism is not completely understood. In this short communication, we present three patients with a colon perforation proximal to the anastomosis, similar to a stercoral perforation, following colorectal cancer resection with application of an intraluminal device, the C-seal.

Opioid drugs and stercoral perforation of the colon: Case report and review of literature

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Patient’s condition was further compounded by splenic rupture.

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Recovery was complicated by post-op sepsis and intraabdominal abscesses.

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Constipation may be missed due to encopresis and the analgesic effects of opioids.

Introduction

Stercoral perforation of the colon is a rare pathology, which is believed to be caused by an increased intraluminal pressure created by a fecaloma. Opioid induced constipation is a rare and often unsuspected cause of colonic perforation.

Presentation of case

We report the case of a 58-year-old woman, who presented to the emergency department (ED) with severe hypotension, abdominal pain and gastrointestinal bleeding. She was found to have a diffusely tender and distended abdomen. Her history was positive for long-term suboxone use and chronic constipation. Abdominopelvic computed tomography (CT) scan revealed a bowel perforation, ascites and fecal impaction. Emergency laparotomy revealed extensive stool in the peritoneal cavity as well as hemoperitoneum. There was a fecal bolus with perforation located in the sigmoid colon. On postoperative day (POD) six, a second abdominopelvic CT scan was performed and results revealed the necessity of a second exploratory laparotomy. She had multiple loculated abscesses within the small bowel and other areas, which were opened and washed out.

Discussion

Due to the inflating use of drugs in the opioid class, the recognition of this pathology has become increasingly important. The action of the drug on the mu-opioid receptors, any patients taking opioid medications are at risk for constipation progressing to stercoral perforation and should be monitored closely.

Conclusion

Patients presenting with chronic constipation, fecal impaction on imaging and clinical signs of peritonitis or sepsis, should consider stercoral perforation in their differential diagnosis since early detection is key to reduce mortality rates in these cases.

Stercoral colitis complicated with ischemic colitis: a double-edge sword

BACKGROUND

Stercoral colitis is a rare inflammatory process involving the colonic wall secondary to fecal impaction with high morbidity and mortality; especially if complicated with ischemic colitis, stercoral ulcer formation and subsequent perforation. There are several case reports published on abdominal perforation resulting from stercoral colitis. However, stercoral colitis complicated by ischemic colitis is rare. The purpose of this case report is to describe the potential challenges in the diagnosis and management of stercoral colitis with ischemic colitis.

CASE PRESENTATION

An 87 years old male with history of chronic constipation presents with severe abdominal pain to the emergency department. The patient was hemodynamically stable. On physical examination, the abdomen was mildly distended with moderate tenderness. Lab work was significant for leukocytosis and lactic acidosis. Abdominal CT scan revealed large amount of retained stool in the colon, bowel wall thickening and infiltration of peri-colonic fat, which were suggestive for stercoral colitis. Patient was started on IV fluids and antibiotics. He was given an enema, followed by laxative and manual disimpaction of stool. Colonoscopy was performed and biopsies were obtained. Tissue biopsy was significant for focal active colitis with regenerative glandular changes and neural hyperplasia.

CONCLUSION

Elevated lactic acid level secondary to ischemia of the bowel wall with CT scan findings aid in establishing the diagnosis of stercoral colitis complicated with ischemic colitis. Urgent treatment with laxatives and fecal disimpaction is indicated to prevent perforation and peritonitis.

Stercoral perforation of the rectosigmoid colon due to chronic constipation: A case report

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The corrections requested by the authors were made.

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Spelling, grammar and syntax, and language errors have been fixed.

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Introduction

Chronic constipation is very common in elderly patients. As a result of this situation fecaloma is also frequently seen at these ages. However, the stercoral perforation caused by fecaloma is a rare situation to occur. The rectosigmoid colon is the most affected colonic segment. It is seen in older patients with concomitant diseases and a low quality of life.

Presentation of case

Here in this case, we have to report an 83 – year-old male patient who came to the emergency room with complaints of abdominal pain and constipation for two days. He had Type II Diabetes Mellitus, had a cardiac stent and also Alzheimer’s disease. We diagnosed a rectosigmoid perforation due to a large fecaloma. This case presentation was prepared in accordance with the scare checklist guidelines (Agha et al., 2016 [1]).

Discussion

Constipation and faecal impaction are common entities, particularly in elderly and bedridden patients. Fecalomas are collections of dehydrated, hardened stool. They rarely can cause colonic ischemia and/or stercoral perforation. Stercoral perforation is the perforation or rupture of the intestine walls by a stercoraceous mass. Stercoral perforation is a very dangerous, life-threatening situation, as well as a surgical emergency, because the spillage of contaminated intestinal contents into the abdominal cavity leads to peritonitis, a rapid bacteremia with many complications.

Conclusion

Fecalomas can cause stercoral perforations. This situation can be confused with other causes of acuteabdomen in these patients. Early surgery can be life saving.

Stercoral perforation of the colon in a heroin addict

A 27-year-old female heroin addict presented with a peritonitic and distended abdomen. Her medical history included depression and a 3-year history of heroin abuse with attendant constipation. CT scan showed free intraperitoneal gas, massive faecal distension of the rectum and sigmoid colon and likely bowel necrosis. She underwent an emergency Hartmann's procedure for perforation of the sigmoid colon. Pathology identified two areas of stercoral ulceration, one of them being the area of perforation. Postoperatively, the patient developed a deep vein thrombosis and is now on anticoagulant therapy. She was discharged 4 weeks after admission. The patient has been reviewed at follow-up clinic by the surgical team and specialist stoma nurses. She is coping well with good stoma function. We will perform a colonoscopy to identify any further areas of stercoral ulceration but there are no plans for further surgery at present.

Stercoral colitis: diagnostic value of CT findings

PURPOSE

We aimed to evaluate the CT findings of stercoral colitis (SC).

METHODS

Forty-one patients diagnosed with SC between February 2006 and April 2015 were retrospectively reviewed.

RESULTS

Rectosigmoid colon was the most frequently involved segment (100%, n=41). CT findings can be summarized as follows: dilatation >6 cm and wall thickening >3 mm of the affected colon segment (100%, n=41), pericolonic fat stranding (100%, n=41), mucosal discontinuity (14.6 %, n=6), presence of free air (14.6%, n=6), free fluid (9.7%, n=4), and pericolonic abscess (2.4%, n=1). The sign most related with mortality was the length of the affected colon segment >40 cm.

CONCLUSION

CT has an important role in SC, since life-threatening complications can be easily revealed by this imaging modality. Increased length of involved colon segment (>40 cm) is more likely to be associated with mortality.

Stercoral Ulcer-Associated Perforation and Chemotherapy

Stercoral ulcer perforation is a life-threatening surgical condition which is thought to result from necrosis of the bowel wall due to an ischemic pressure by stool. This condition usually afflicts patients with chronic constipation. CT scan can identify most of the cases and emergent surgery is usually indicated.

Stercoral perforation of the rectum with faecal peritonitis and pneumatosis coli: A case Report

Colonic perforation due to impacted faeces or faecaloma is a relatively uncommon presentation with grave prognosis. If left untreated, it can be life threatening due to complications like faecal peritonitis. Till date, fewer than 150 cases have been reported mostly in the English surgical literature describing constipation as the most common underlying etiology. Involvement of rectum is rare with very limited data published in this context. We present a case of stercoral perforation involving the rectum with associated faecal peritonitis and pneumatosis coli.

Not your usual constipation: stercoral perforation

Stercoral perforation is a rare cause of bowel perforation. It is caused by faecal impaction, which generates pressure against the colon wall, leading to ischaemic necrosis and subsequent perforation. Since diagnosis is often delayed, stercoral perforation is usually mistreated as constipation or faecal impaction, leading to high mortality. This report presents a case of stercoral perforation in a woman aged 34 years who was promptly diagnosed and successfully treated.

[Stercoral perforation of the colon: case report and literature review]

INTRODUCTION

Colon perforation has several causes, including stercoral perforation of the colon, which was first described in 1894. Currently, reported cases are fewer than 100.

CASE REPORT

Male patient of 67 years old, treated at Huichapan General Hospital, Hidalgo, Mexico, with abdominal pain, bloating and no bowel movements. He referred being constipated for the last ten years. Imaging revealed an extremely dilated sigmoid colon with fecal matter as well as free gas in the peritoneal cavity. The suspicion of stercoral colonic perforation is established. Exploratory laparotomy was performed immediately, finding a perforation and a hard scybalum protruding in the ascending colon. Colectomy, ileostomy and Hartmann's pouch are performed. After surgery, the condition of the patient worsened and progressed to septic shock and respiratory failure. The patient died four hours after surgery, with the diagnosis of organ failure due to sepsis.

LITERATURE REVIEW

Stercoral perforation accounts for 3.2% of all colon perforations and is caused by a rupture of the intestinal wall through direct pressure of a fecaloma on the colon. It occurs especially in patients older than 70 years with severe chronic constipation, weakened and/or are hospitalized with multiple medications and immobilized.

CONCLUSIONS

Stercoral perforation of the colon is a rare cause of bowel perforation, which should be suspected in patients with a history of chronic constipation, acute abdominal pain, bloating and sepsis, in order to intervene in a timely fashion.

A Case of Stercoral Perforation Detected on CT Requiring Proctocolectomy in a Heroin-Dependent Patient

Stercoral perforation of the colon is rare but carries with it significant morbidity and mortality. Stercoral perforation usually occurs in elderly, immobile patients with chronic constipation. In this manuscript, we report the case of stercoral perforation in a patient due to chronic heroin dependence. We report the case of a 56-year-old male patient with stercoral perforation, diagnosed by computed tomography, secondary to heroin dependence, requiring proctocolectomy and an end ileostomy. There are very few reports in the literature describing cases of stercoral perforation and questions have been asked about the importance of preoperative cross-sectional imaging. In our case, the diagnosis of stercoral perforation was made only on CT. Although this is not the first such case to be reported, it is significant as preoperative CT imaging was influential not only in determining the aetiology of the abdominal distension seen on the plain film, but also in detecting the pneumoperitoneum which was not evident clinically or on plain radiographs.