Imaging manifestations of faecal impaction and stercoral perforation

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 Secondary to Opiate-Induced Constipation

The authors present the case of a 62-year-old woman who had stercoral colitis secondary to opiate use for rheumatoid arthritis leading to chronic constipation. Computed tomography imaging demonstrated stool along a significant length of the colon. Stercoral colitis is a seldom suspected cause of severe abdominal pain. Although constipation may seem benign, when it gets to the level of a stercoral colitis, mortality due to colonic perforation is a very real concern. The authors review the presentation, risk factors, and management of stercoral colitis.

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.

Diagnosis and emergency surgical management of stercoral colitis-induced colonic ischemia: A case report and literature review

INTRODUCTION AND IMPORTANCE

Stercoral colitis is an urgent complication of fecal impaction that requires aggressive management. The rare complicated with bowel ischemia requires a high index of suspicion for early diagnosis. This case report describes the detection and management of this rare and fatal complication of stercoral colitis.

CASE PRESENTATION

An 80-year-old man presented after 3 days of obstipation. Abdominal plain radiography revealed several air-fluid levels in the colon with centralized small bowel gas. Computed tomography revealed fecal impaction and stercoral colitis without evidence of bowel ischemia.

CLINICAL DISCUSSION

Fecal impaction and stercoral colitis without evidence of bowel ischemia was suspected. Owing to the development of refractory septic shock, we performed damage control surgery. Definitive surgery with end ileostomy was follow by 48 h later. The patient was discharged home safely.

CONCLUSION

Stercoral colitis-induced ischemia is rare but potentially fatal; ischemia should be highly suspected. CT can help diagnosed of stercoral colitis but no single parameters for diagnosed of bowel ischemia. Prompt resuscitation and surgical exploration with damage control surgery are recommended.

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.

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.

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.

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.

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.

Large Bowel Obstruction in the Emergency Department: Imaging Spectrum of Common and Uncommon Causes

Although large bowel obstruction (LBO) is less common than small bowel obstruction, it is associated with high morbidity and mortality due to delayed diagnosis and/or treatment. Plain radiographs are sufficient to diagnose LBO in a majority of patients. However, further evaluation with multidetector computed tomography (MDCT) has become the standard of care to identify the site, severity, and etiology of obstruction. In this comprehensive review, we illustrate the various causes of LBO emphasizing the role of MDCT in the initial diagnosis and detection of complications along with the tips to differentiate from disease which can mimic LBO.

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.

Role of Multidetector Computed Tomography in the Diagnosis of Colorectal Perforations

Colonic perforations can be classified into perforations that occur at the site of a localized pathologic process and cecal perforations that occur secondary to distal colonic obstructions. Rectal perforations may result from foreign bodies inserted into the rectum; moreover, deep rectal biopsies, polypectomy, improper cleansing enema, or thermometer placement may also lead to rectal perforation. Correct identification of the cause and site of the perforation is crucial for appropriate management and surgical planning. Multidetector row computed tomography has a pivot role in planning the type of operative treatment, the prognosis, and in assessing those patients who have clinical symptoms of peritonitis but no radiographic signs of perforation.

Giant faecaloma-a rare cause of life-threatening lower gastrointestinal haemorrhage

Chronic constipation and faecal impaction are common in the elderly, particularly in institutionalized patients and those with neurological impairment. Faecaloma formation is an extreme manifestation of coprostasis that can lead to stercoral ulcerations and perforation, a recognized severe complication. We present the case of an uncommon life-threatening complication resulting from a giant rectal faecaloma, which has rarely been reported in the literature. The patient presented with haemodynamic shock from profuse per-rectum haemorrhage. Clinical examination revealed a hard central abdominal mass and triple-phase CT of the abdomen demonstrated a tumour-like mass of hard stool in the rectum measuring up to 25 cm and stretching the adjacent vasculature, causing intraluminal active arterial haemorrhage. Emergency selective arterial embolization performed by the interventional radiologists successfully controlled the bleeding with a good outcome. This case highlights a rare but possibly fatal complication of chronic constipation and emphasizes the importance of having access to an acute interventional radiology service capable of promptly dealingwith life-threatening presentations.

Evaluating the Patient with Left Lower Quadrant Abdominal Pain

Left lower quadrant pain is a frequent indication for imaging in the emergency department. Most causes of pain originate from the colon, including diverticulitis, colitis, fecal impaction, and epiploic appendagitis. Left-sided urolithiasis and spontaneous hemorrhage in the retroperitoneum or rectus sheath are additional causes of pain. Computed tomography is the preferred imaging modality in the emergent setting for all of these pathologic conditions. Gynecologic, testicular, and neoplastic pathology may also cause left lower quadrant pain but are not discussed in this article.

Management of intestinal obstruction in advanced malignancy

Patients with incurable, advanced abdominal or pelvic malignancy often present to acute surgical departments with symptoms and signs of intestinal obstruction. It is rare for bowel strangulation to occur in these presentations, and spontaneous resolution often occurs, so the luxury of time should be afforded while decisions are made regarding surgery. Cross-sectional imaging is valuable in determining the underlying mechanism and pathology. The majority of these patients will not be suitable for an operation, and will be best managed in conjunction with a palliative medicine team. Surgeons require a good working knowledge of the mechanisms of action of anti-emetics, anti-secretories and analgesics to tailor early management to individual patients, while decisions regarding potential surgery are made. Deciding if and when to perform operative intervention in this group is complex, and fraught with both technical and emotional challenges. Surgery in this group is highly morbid, with no current evidence available concerning quality of life following surgery. The limited evidence concerning operative strategy suggests that resection and primary anastomosis results in improved survival, over bypass or stoma formation. Realistic prognostication and involvement of the patient, care-givers and the multidisciplinary team in treatment decisions is mandatory if optimum outcomes are to be achieved.

Stercoral Perforation of the Colon: A Potentially Fatal Complication of Opioid-Induced Constipation

Stercoral perforation of the colon is a rare complication of constipation, and there have only been a few reported cases of stercoral perforation of the colon secondary to opioid-induced constipation. This article describes such a case in a cancer survivor with chronic cancer-related pain and reviews the medical/surgical literature on stercoral perforation of the colon.

Stercoral Perforation of the Colon during Pregnancy: A Case Report and Review of the Literature

Stercoral perforation of the colon, though rare, is associated with high mortality. Review of the literature identified only three prior cases reported during pregnancy. We report a case on a multiparous female presenting at 31 weeks of gestation with acute abdominal pain. Computed tomography suggested a sigmoid colon perforation. An urgent exploratory laparotomy was performed where feculent peritonitis and a stercoral perforation of the sigmoid colon was confirmed. A cesarean delivery and sigmoid colectomy with descending end colostomy was performed. While the newborn had an uncomplicated course, the mother developed an intra-abdominal abscess requiring operative management.

Colorectal emergencies and related complications: a comprehensive imaging review--noninfectious and noninflammatory emergencies of colon

OBJECTIVE

In this article, we illustrate imaging findings of colorectal emergencies encountered in the acute setting that are primarily noninfectious and noninflammatory in origin. Our review should enable the reader to identify and understand common colorectal emergencies and related complications in clinical practice.

CONCLUSION

The diagnosis of colorectal emergencies is mostly straightforward, but it can be challenging because of the overlap of presenting symptoms and imaging findings. Therefore, it is essential to clarify the cause, narrow the differential diagnosis, and identify associated complications.

Stercoral perforation of the sigmoid colon in a schizophrenic patient

Stercoral perforation of the colon is a life threatening condition, due to pressure necrosis by hard fecaloma which, are commonly found in chronic constipated patients. We report the case of a 45-year-old schizophrenic woman, under psychiatric treatment for two years, presenting with a 10-day history of absolute obstipation and distension. On physical examination the patient had signs of generalized peritonitis. Preoperative diagnostic workup gave no clear-cut clues about diagnosis. Emergency laparotomy revealed a single perforation over the antimesentric border of the sigmoid colon with hard fecal matter protruding through perforation margin. A segmental resection of the sigmoid colon with colonic lavage and end to end anastomosis was performed. The patient made an uneventful recovery. We have discussed the diagnostic work-up, and the management of this rare entity. Patient was on antipsychotic, anticholenergic and NSAID'S drugs for long time with longstanding immobilisation and poor oral intake. Association of these etiological factors with chronic constipation which ultimately leads to stercoral perforation have been corroborated.

A systematic review of stercoral perforation

AIM

Stercoral perforation is a rarely suspected life-threatening condition. Early diagnosis is difficult but essential. A comprehensive systematic review was performed to evaluate its presentation, diagnosis and treatment.

METHOD

A systematic review was carried out of Embase, MEDLINE, PubMed and Cochrane databases for all articles published between 1998 and 2011. Only studies describing stercoral perforation were included.

RESULTS

Twenty-four relevant articles were found including 137 patients (median age = 62 years) with stercoral perforation, of whom 81% had chronic constipation. Stercoral perforation was diagnosed by CT scan in 90% of 31 patients, with the commonest findings being a combination of faecal impaction (84%) and subphrenic (90%) or extraluminal air (61%). The commonest site of perforation was the sigmoid colon (50%) followed by the rectosigmoid junction (24%). The overall mortality was 34%.

CONCLUSION

Stercoral perforation should be suspected in elderly and chronically constipated patients with unexplained abdominal pain and investigated appropriately with a CT scan to allow timely and optimal treatment.

A stercoral perforation of the rectum

A stercoral perforation of the rectum due to a fecaloma is a rare disease with a high mortality rate. Although multiple case reports of colonic perforations have been published, the data regarding rectal perforations are limited. This case report will highlight one such case of a stercoral rectal perforation that was successfully treated with a laparoscopic operation.

Uncommon causes of acute abdominal pain: multidetector computed tomography pearls and pitfalls for the radiologist on call

We review uncommon causes of acute abdominal pain in which inconclusive multidetector computed tomography (MDCT) studies were followed by emergency surgery and unexpected diagnoses. Despite dedicated protocols and technical advances, MDCT of uncommon causes of acute abdominal pain still represents a significant challenge for the radiologist on call. We emphasize diagnostic pearls and pitfalls that may help the radiologist on call identify or suspect these uncommon causes of acute abdominal pain on MDCT.

A stercoral perforation of the descending colon

This is a case report on a stercoral perforation of the descending colon that was not adequately treated in the first operation. Re-operation was required in order to revise the primary repair site and to remove the impacted fecaloma.