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

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.

The added value of multidetector CT in the diagnosis of gastrointestinal causes of acute abdomen in geriatrics

Background

Due to changes in the gastrointestinal system in geriatric people, there are higher rates of atypical presentations of common disorders. In order to decrease the mortality rate, an efficient and correct diagnosis should be given for these patients. The aim of this study was to assess the role of MDCT in evaluating gastrointestinal tract-related acute abdominal pain in geriatric patients.

Results

Among fifty geriatric patients presented clinically with acute abdominal pain of gastrointestinal origin from November 2019 to September 2020, mean age was 70.2 ± 5.6 years ranging from 65 to 86 years. Majority were female, (thirty patients, 60%). Gastric causes (16%): obstruction (62.5%) and perforation (37.5%); and intestinal causes (84%): obstruction (71.4%), inflammatory (28.6%), perforation (23.8%), vascular (11.9%), and others (2.4%) were the frequent causes of acute abdominal pain in the studied patients. MDCT had a very high sensitivity of 98% (95% CI) as well as its PPV (95% CI) was 100% in the evaluation of gastrointestinal-related acute abdominal pain.

Conclusion

MDCT is a reliable diagnostic imaging modality for geriatric patients presented with acute abdominal pain suggested to be of gastrointestinal origin with a very high sensitivity in diagnosing the causative pathological conditions. MDCT can efficiently differentiate between obstructive, inflammatory, perforated, and ischemic bowel disorders.

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.

Adenocarcinoma de colon sigmoide metastásico en paciente joven, presentación atípica: reporte de caso

El adenocarcinoma colorrectal es la tercera causa de muerte por cáncer en mujeres y la cuarta en hombres a nivel mundial. Se diagnostica en su mayoría en pacientes mayores a los 50 años, siendo la edad media al momento del diagnóstico los 72 años. A pesar eso, se estima que en los próximos años aumentará la incidencia en personas jóvenes y de mediana edad. Debido a esta proyección y considerando que la ausencia de signos y síntomas específicos no permite un diagnóstico oportuno, se hacen necesarias la sensibilización clínica y un alto índice de sospecha en las presentaciones atípicas. Se presenta el caso de una paciente joven que consulta por un cuadro de un mes de síntomas respiratorios quien, después de tratamiento antibiótico, antiviral e inmunomodulador sistémico, presenta sepsis de origen abdominal por peritonitis de cuatro cuadrantes secundaria a perforación de colon sigmoide debida a adenocarcinoma bien diferenciado, metastásico a pulmón, que la llevó a la muerte.

Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology

Gastrointestinal tract (GIT) perforation is a common medical emergency associated with considerable mortality, ranging from 30 to 50%. Clinical presentation varies: oesophageal perforations can present with acute chest pain, odynophagia and vomiting, gastroduodenal perforations with acute severe abdominal pain, while colonic perforations tend to follow a slower progression course with secondary bacterial peritonitis or localised abscesses. A subset of patients may present with delayed symptoms, abscess mimicking an abdominal mass, or with sepsis.

Direct multidetector computed tomography (MDCT) findings support the diagnosis and localise the perforation site while ancillary findings may suggest underlying conditions that need further investigation following primary repair of ruptured bowel. MDCT findings include extraluminal gas, visible bowel wall discontinuity, extraluminal contrast, bowel wall thickening, abnormal mural enhancement, localised fat stranding and/or free fluid, as well as localised phlegmon or abscess in contained perforations.

The purpose of this article is to review the spectrum of MDCT findings encountered in GIT perforation and emphasise the MDCT and clinical clues suggestive of the underlying aetiology and localisation of perforation site.

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.