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International Journal of Gerontology 5 (2011) 6263

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International Journal of Gerontology


journal homepage: www.ijge-online.com

Letter to the Editor

An Atypical and Fatal Case of Stercoral Perforation of Sigmoid Colony

We read with interest the case about stercoral perforation of the sigmoid colon in your journal1. We present another rare case with delayed progression of peritoneal signs and fatal outcome. A 76-year-old woman was brought to our emergency department because of lower abdominal pain with minimal rectal bleeding after a difcult defecation at 6 oclock in the morning. She had history of lumbar spine compression fracture with immobility and chronic constipation. She took nonsteroid anti-inammatory drugs (NSAIDs) and opioids for pain relief and stool softener and laxative agents for constipation for a long time. When arrived, her temperature was 37.3 C, pulse rate of 105/min, respiration rate of 22/min, and the blood pressure was 120/75 mmHg. Physical examination showed moderately distended abdomen with lower abdominal tender and without guarding or rebounding tenderness.

A supine abdominal radiography revealed much stool in pelvic area and without evidence of bowel obstruction. Laboratory tests were unremarkable. Neither leukocytosis nor anemia was detected. A presumptive diagnosis of lower gastrointestinal bleeding with stool impaction was made. Her lower abdominal pain remained dull and intermittent cramping with uid resuscitation and pain control. Unfortunately, she deteriorated with increasing abdominal pain and respiratory distress within 5 hours of presentation. Peritoneal signs and shock (85/50 mmHg) developed. In retrospect, pneumoretroperitoneum was identied on the plain abdomen (Fig. 1). Abdominal computed tomography (CT) demonstrated much extraluminal fecal material in pelvic cavity because of a large defect at sigmoid colon and free air accumulated in retroperitoneal and perirenal area (Figs. 2 and 3). A diagnosis of sigmoid perforation with septic shock was made. Because of severe septic shock despite aggressive uid resuscitation and inotropic agents, surgical intervention was not carried out. The patient died of profound shock at 3:00 pm within 9 hours of onset of symptoms. Stercoral perforation of the colon is a rare and serious condition. The preoperative diagnosis is seldom made. Chronic constipation is considered the main cause of stercoral perforation of the colon. Pressure of constipation causes the chronic inammation, necrosis, and ischemic change of colon mucosa. The pressure is frequently powerful at sigmoid or rectosigmoid colon because of its relative narrowing of bowel lumen, especially in the antimesenteric aspect for poorer blood perfusion2. Some medications increase the risk of stercoral perforation of colon by inducing constipation, such as NSAIDs, aluminum-based antacids, antidepressants, and opioids1.

Fig. 1. Supine abdominal lm shows fecal impaction in pelvis. Retroperitoneal gas (arrows) is identied retrospectively. Fig. 2. Abdominal CT demonstrates a large defect of sigmoid colon (arrows) and much fecal loading in pelvis. CT computed tomography.

All contributing authors declare no conict of interest.

1873-9598/$ see front matter Copyright 2011, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.ijge.2011.01.013

Letter to the Editor

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symptoms and rapid fatal progression within 9 hours of presentation. We thought retroperitoneal irritation did not cause obvious peritoneal signs. Physical examination and laboratory tests revealed no evidence of sepsis and peritonitis. Pneumoretroperitoneum was not identied at rst look in plain lm of abdomen. Then the patient developed fatal shock and poor condition for surgical management. We missed the golden time for accurate diagnosis and treatment. In conclusion, stercoral perforation of the colon can present without obvious peritoneal sign and rapid course of sepsis. Plain abdominal radiography shows free air and marked fecal impaction barely in most instances. CT may allow for timely diagnosis of stercoral perforation of colon.

References
1. Tsai AY, Chao ST, Yan HM. Stercoral perforation of the sigmoid colon. Int J Gerontol 2008;2:233235. 2. Yano T, Wakabayashi H, Yachida S, et al. A stercoral perforation of the colon with an obvious faecal mass diagnosed by computed tomography. ANZ J Surg 2008;78: 214215. 3. Rozenblit AM, Cohen-Schwartz D, Wolf EL, et al. Stercoral perforation of the sigmoid colon: computed tomography ndings. Clin Radiol 2000;55:727729. 4. Dubinsky I. Stercoral perforation of the colon: case report and review of the literature. J Emerg Med 1996;14:323325.

Fig. 3. Another level of CT reveals retroperitoneal and left perirenal gas. CT computed tomography.

Risk factors of stercoral perforation of colon in our patient included her immobility and medications (NSAIDs and opioids). Abdominal radiography of stercoral perforation of the colon usually showed the fecal loading in the pelvis. CT is a sensitive tool for diagnosis. It shows the defect of the perforated colon, extraluminal scybala, and free air of perforated viscus in peritoneum or retroperitoneum3. In terms of managing the stercoral perforation of colon, resection of the involved segment and exteriorization of the colon is probably preferred to avoid leakage of the anastomosis. Other surgical interventions, such as simple exteriorization of the perforated colon or primary closure of the ulcer without resection, have been reported in the literature. The better mortality is 32% with surgical resection and exteriorization4. Our case had atypical

I-Tsung Lin, Ming-Jong Bair*, Huan-Lin Chen, Chin-Hsien Lee Division of Gastroenterology, Department of Internal Medicine, Taitung Branch of Mackay Memorial Hospital, Taitung, Taiwan * Correspondence to: Dr Ming-Jong Bair, Division of Gastroenterology, Department of Internal Medicine, Taitung Branch of Mackay Memorial Hospital, Taitung, Taiwan. Tel.: 886 89 310150; fax: 886 89 321240. E-mail address: a5963@ttms.mmh.org.tw (M.-J. Bair). Available online 10 March 2011