Clinical Analysis of Stercoral Perforation of the Colon

Jung Kwang Nam; Byung Seok Kim; Kyung Soo Kim; Duk Jin Moon

doi:10.4166/kjg.2010.55.1.46

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Nam, Kim, Kim, and Moon: Clinical Analysis of Stercoral Perforation of the Colon

Original Article

Korean J Gastroenterol 2010;55(1):46-51.

Published online: 21 February 2010

DOI: https://doi.org/10.4166/kjg.2010.55.1.46

Clinical Analysis of Stercoral Perforation of the Colon

Jung Kwang Nam, M.D., Byung Seok Kim, M.D., Kyung Soo Kim, M.D.^∗, Duk Jin Moon, M.D.

Department of Surgery, Kwangju Christian Hospital, Gwangju, Korea

^∗Department of Pathology, Kwangju Christian Hospital, Gwangju, Korea

Correspondence to: Byung Seok Kim, M.D. Department of Surgery, Kwangju Christian Hospital, 264, Yangrim-dong, Nam-gu, Gwangju 503-715, Korea Tel: +82-62-650-5035, Fax: +82-62-671-7447 E-mail: abdomen@medimail.co.kr

Received 28 July 2009 Accepted 29 October 2009

Abstract

Background/Aims

A stercoral perforation of the colon (SPC) is a rare, life-threatening disease. The aim of this study was to represent the definition of SPC and help the diagnosis and treatment of this condition.

Methods

We reviewed 92 medical records of patients who underwent operation due to colonic perforation from January 2000 to February 2009 retrospectively. Maurer's diagnostic criteria were used for the diagnosis of SPC.

Results

Eight patients (8.7%) were diagnosed as SPC. The age of the patients ranged from 59 to 85 years old. All of the patients were female and had a history of long-standing constipation. Only two patients (25%) were diagnosed as SPC preoperatively. The site of perforation of all patients was sigmoid colon. The methods of operation were Hartmann's procedure (7 cases), and primary repair with sigmoid loop colostomy (1 case). There were one recurrence and two deaths (25%) due to sepsis and multiple organ failure.

Conclusions

SPC should be considered in chronically constipated, and bedridden patients who present with acute abdomen. Hartmann's procedure is the treatment of choice in most situations. Mortality is high but can be minimized with early definitive surgery.

Keywords: Perforation, Stercoral, Perforation, Colonic, Constipation, Chronic

REFERENCES

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Fig. 1.

68-year-old female with stercoral perforation of colon. (A) Transverse CT image showed fecaloma protruding through the wall defect of the sigmoid colon (arrowhead). (B) Transverse CT image obtained at upper level showed extra-luminal fecal material (arrow) and free gas (arrowhead).

Fig. 2.

Microscopic findings of the colonic wall around the perforation. It showed clear-cut denudation of mucosa and submucosa with exposure of muscular layer. Marked vascular congestion and mild chronic inflammation were noted (H&E stain, ×100).

Table 1.

Diagnostic Criteria of Stercoral Perforation of the Colon²

1) The colonic perforation is round or ovoid, exceeds 1 cm in diameter, and lies antimesenterial
2) Fecalomas are present within the colon, protruding through the perforation site or lying within the abdominal cavity
3) Pressure necrosis or ulcer and chronic inflammatory reaction around the perforation site are present microscopically
4) Colonic perforations associated with an abdominal trauma or with another colonic pathology^∗ were excluded

^∗ Such as distal obstruction of the large bowel, diverticulitis, inflammatory bowel disease, mesenteric vasculopathy, sclero-dermatous colon, pneumatosis coli, Hirschsprung's disease.

Table 2.

Causes of Colonic Perforation from Jan 2000 to Feb 2009

Causes	Number (%)
Diverticulitis	34 (37.0)
Iatrogenic	19 (20.7)
Trauma	14 (15.2)
Cancer	9 (9.8)
Stercoral	8 (8.7)
Idiopathic	4 (4.3)
Others	4 (4.3)
Total	92 (100)

Table 3.

Clinical Findings of Stercoral Perforation Patients

Case	Age/Sex	Previous operation history	Predisposing factor
1	85/F	−	NSAIDs
2	84/F	Subtotal gastrectomy	Ca^2＋channel blocker, NSAIDs
3	70/F	Miles'operation	NSAIDs
4	68/F	−	b-Blocker, NSAIDs
5	71/F	−	NSAIDs, DM, bed ridden
6	59/F	−	Al-Mg hydroxide NSAIDs
7	75/F	−	Ca^2＋channel blocker, NSAIDs
8	80/F	−	NSAIDs

NSAIDs, non-steroidal anti-inflammatory drugs; DM, diabetes mellitus; Al-Mg hydroxide, aluminum-magnesium hydroxide.

Table 4.

Radiologic Findings of Stercoral Perforation Patients

Case	Free air below the diaphragm at X-ray^∗	CT findings	Preoperative diagnosis
1	−	Faecal accumulation at the perforation level, pericolic fat stranding,	Perforated appendicitis
		interloopal free gas
2	＋	Faecal accumulation at the perforation level, pericolic fat stranding,	Unknown colon perforation
		subphrenic and interloopal free gas
3	＋	Faecal accumulation at the perforation level, pericolic fat stranding,	Unknown colon perforation
		subphrenic and interloopal free gas
4	＋	Faecal accumulation at the perforation level, colonic wall defect,	Unknown colon perforation
		pericolic fat stranding, subphrenic and interloopal free gas
5	−	Wall thickening of duodenal 2^nd portion	Duodenal ulcer perforation
6	＋	Faecal accumulation at the perforation level, colonic wall defect,	Stercoral perforation
		pericolic fat stranding, subphrenic and interloopal free gas
7	−	Faecal accumulation at the perforation level, pericolic fat stranding,	Rectal cancer perforation
		interloopal free gas
8	＋	Faecal accumulation at the perforation level, colonic wall defect,	Stercoral perforation
		pericolic fat stranding, subphrenic and interloopal free gas

^∗ at X-ray, at preoperatively simple chest X-ray.

Table 5.

Operative Findings, Procedures, and Outcomes

Case	Localization	Size of perforation (cm)	Name of procedure	Post-operative complication	Mortality
1	S.C	2×2	H.P	Sepsis, ARF	＋
2	S.C	8×7	H.P, splenectomy	Sepsis, ARDS	＋
3	S.C	2×1	Primary closure, S.C loop colostomy	Wound infection	−
4	S.C	4×3	H.P	ARF	−
5	S.C	2×2	H.P	Sepsis	−
6	S.C	3×2	H.P	Sepsis, ARF	−
7	S.C	3×3	H.P	Wound infection	−
8	S.C	2×3	H.P	Sepsis, ARF recurrence	−

S.C, sigmoid colon; H.P, Hartmann's procedure; ARF, acute renal failure; ARDS, acute respiratory distress syndrome.

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