EP228 - The Dangers of Perforated Atypical Stercoral Colitis

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Purpose/Background: Stercoral colitis is a condition in which fecal impaction leads to surrounding inflammation along the adjacent colon. It arises in approximately 3% of patients with fecal impaction. The even rarer occurrence of perforation from stercoral colitis results from the ischemia and necrosis caused by pressure placed on adjacent mucosa from the fecalith. In patients with stercoral colitis, perforation is observed in 0.7% of cases, with a mortality rate of 35%.

Methods/Interventions: This is a case of a 71-year-old male who presented to the hospital with six days of severe constipation. CT imaging revealed colonic distention with calcified colonic fecalith in the descending colon just proximal to the splenic flexure. Despite an aggressive bowel regimen and conservative management upon admission, his symptoms persisted. Colonoscopic dislodgement and removal was attempted prior to surgical intervention. Colonoscopy was unsuccessful in removing the fecalith and demonstrating severe mucosal ulceration and inflammation. Post-operative CT imaging demonstrated micro-perforation at the site of the fecalith.

Results/Outcomes: The patient was urgently taken to the operating room for diagnostic laparoscopy and hand-assisted left colectomy. Intraoperatively, upon mobilization of the splenic flexure, the perforation site was adjacent to the large fecalith along the superior aspect of the left colon. The diseased portion of the colon was resected, and the fecalith was removed. The pathology returned consistent with stercoral ulcerations and micro-perforation.

Conclusion/Discussion: Perforation from stercoral ulceration is a serious condition requiring prompt identification and treatment. This patient's stercoral ulceration and subsequent perforation was unusual due to its proximal location. Stercoral ulcerations are commonly along the rectosigmoid junction, as this is the narrowest portion of the colon. Common risk factors include elderly (>60 years old), limited mobility due to osteoarthritis, end-stage renal disease, poor fiber intake, and malnutrition. The mainstay of stercoral colitis treatment is non-operative management, which includes hydration, limiting opioids, anti-cholinergic drugs, disimpaction, and enemas. Endoscopy can be used as an adjunct when there is concern of failure in medical management. In the event of perforation, diverting colostomy for source control is recommended in unstable patients; however, resection with anastomosis is favored in stable patients. In this case, the patient underwent a colectomy with anastomosis. He had multiple risk factors, including malnutrition, end-stage renal disease, and severe constipation, leading to a failure in non-operative medical management. In conclusion, it is critical to promptly identify and manage stercoral colitis as perforation is associated with a high mortality.