Case presentation

2008-04-18
R1
 Case
@ 66/M
Present illness
Chronic constipation hx.
1 defecation .
3 epigastric discomfort.
abrupt periumbilical sever pain. Plain
abdomen x-ray free air transfer.
4cm perforation at cecum,
antemesenteric side
No intraluminal lesion
No tumorous lesion
Cecum and ascending
colon adhesion
with inflammatory
appearance
with dirty material.
Mucosa unremarkable
Pathology
Microscopic
 Stercoral colitis
Definition
Inflammatory process of colonic wall
related to fecal impaction
Main causative factor : Severe chronic constipation
elderly : often live in nursing homes
young patients : neurologically impaired
slow transit time : opiates, tricyclic antidepressants,
tranquilizers
 Stercoral colitis
Mechanism
Conglomeration of dehydrated fecal material
Increased intraluminal pressure
Decreases blood supply
Ischemia ulceration and perforation
Nevertheless
Stercoral ulceration does not always occur among
constipation cases
Not every stercoral ulceration results in colon
perforation.
 Stercoral colitis
Stercoral ulceration:
M/C in antimesenteric aspect of sigmoid colon
hypoperfusive status
decreasing water content in the stool
narrow diameter
high intraluminal pressures
 CT Finding
Uncomplicated
fecal impaction

Stranding of
pericolonic fat

Presence of
-extraluminal
bubbles of gas
-abscess
 Diagnosis
Hystory of chronic constipation or fecal impaction
Intraoperative findings
generalized peritonitis, colonic dilatation
colonic perforation size 1 cm or more
ulcerations on the antimesenteric border
If frank perforation occurs
-> fecal material within the peritoneal cavity
in close proximity to the perforation site
Histology
transmural necrosis
ulcer margins sharply demarcated
nonspecific inflammatory changes
no additional colonic pathology is found
 Treatment
Most cases of uncomplicated stercoral colitis
successfully treated with disimpaction
Stercoral perforation
broad spectrum antibiotics : initiated in all the patient
resection of the colon segment with an end colostomy
primary repair
Underlying disease Tx
Mortality related to stercoral perforation
: 30% to 55% , prompt exploration may decrease that rate
 Reference
Stercoral Colitis Leading to Fatal Peritonitis: CT
Findings Cathleen et al.
AJR 2005; 184:1189-1193
Management of patients with stercoral
perforation of the sigmoid colon: Report of five
cases Wen-Shih Huang et al.
World J Gastroenterol 2006 January 21;12(3):500-503
Image of the MonthPerforated Stercoral Ulcer
Arch Surg. 2007;142(1):98