EP499 - Lessons Learned From An Obstructing Sigmoid Colon Cancer With Concomitant Crohn’s Disease Presenting As Walled-off Bowel Perforation From Santol Seeds

Purpose/Background: Stercoral perforation occurs from an increase in bowel wall pressure, often from an obstructing fecaloma, eventually causing ischemic necrosis and erosion. Santol, also known as sandorica (fr genus Sandoricum), is an endemic tropical seed fruit grown in Southeast Asia. A generations-old practice is swallowing its seeds whole, and reports have associated this with bowel perforation.
Bowel perforation is not a direct result of the actual seed, or its contour, but an underlying bowel pathology usually predisposes to its occurrence. Other causes are fecal impaction from chronic constipation, obstruction from tumors or strictures, bowel inflammation from diverticulitis, and inflammatory bowel disease. Urgent surgical management is often necessary to achieve source control and address the primary pathology.

Methods/Interventions: A 68-year-old male presented with a 4-week history of a gradually-enlarging bulge on the left inguinal area, and constipation. He eventually developed abdominal pain and distention, and vomiting. At the ED, he was seen septic, with noticeable erythema and tenderness on the left inguinal area. (Fig 1A)

Plain radiographs showed nondilated small bowels and a closed-loop dilation of the colon with a cut-off at the sigmoid. A CT scan done 2 weeks prior showed small hyperdense foci—the santol seeds--located intraluminally at the sigmoid, with communication to the adjacent abdominal wall. (Fig 1B) The impression was a walled-off bowel perforation from the seeds with underlying diverticular disease.

Results/Outcomes: An emergent Hartmann’s procedure was done. There was generalized peritonitis with intra-abdominal fecal spillage. Santol seeds were evacuated from a walled-off cavity formed by the adherence of the sigmoid to the abdominal wall. (Fig 1C) A fibrotic bowel segment distal to the perforation, the apparent cause of the obstructive symptoms, was seen on the cut-specimen. (Fig1D and 1E) The histopathology report showed sigmoid adenocarcinoma Stage IIIB (T4aN1Mx), with a background of Crohn’s disease.

Conclusion/Discussion: Given the histopathologic findings of malignant disease, a Hartmann’s procedure may not have been the most appropriate procedure. In the absence of a prior biopsy, and with cancer being one the known causes of bowel perforation—whether associated with santol seeds or not, an oncologic resection should have been done. This would have entailed an en bloc resection of the involved abdominal wall, including the skin. Albeit likely ending up with a large anterior abdominal wall defect, this may be covered using a transfer bag needing multiple changes until the wound bed is viable and ready for a muscle flap. Also, a review of the CT scan already clearly showed the stricture distal to the seeds. A malignant nature should have been considered. Due to its advanced nature, further management would consist of adjuvant chemotherapy +/- targeted therapy and surveillance.

Figure1A-E
Figure 1 A. Left inguinal bulge with associated skin changes and tenderness. B. Abdominal CT scan (coronal cut) showing the intraluminal hyperdense foci (santol seeds) at the sigmoid colon with a visible abdominal wall defect. Distal to the seeds is an evident lesion causing the obstruction. C. Intraoperative photo of the left lower quadrant abdominal wall defect. D. Sigmoid colon specimen showing the site of perforation that was adherent to the abdominal wall defect. E. Cut specimen showing the strictured portion. PGH, 2024.