EP906 - Stercoral Perforation Presenting With Hemoperitoneum And Hematochezia

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Purpose/Background: Stercoral perforation is a rare, but lethal disease which is a consequence of severe constipation. Though it represents only 3.2% of colonic perforations, its mortality rate has been quoted from 32 to 57%. Stercoral perforation typically presents in elderly and bedridden patients with findings of abdominal pain, fever, and sepsis. Rarely, they may present with hematochezia secondary to bleeding stercoral ulcers. Typical imaging findings include fecal impaction and evidence of bowel wall ischemia. This report highlights a unique case of rectal perforation from stercoral colitis that presented with hemoperitoneum and hematochezia.

Methods/Interventions: A 65 year old female with history of chronic constipation presented to an outside facility with abdominal pain and hematochezia. Her history was significant for severe constipation, with last bowel movement that morning which required digital assistance to evacuate. She subsequently developed lower abdominal pain, moderate bright red blood per rectum, nausea and vomiting.
She had a leukocytosis and an adequate, but down-trending, hemoglobin. CT scan showed fecal impaction, intraabdominal free fluid, and posterior wall necrosis and perforation at the proximal rectum, with free air confined to the retroperitoneum. There was active extravasation within the rectum.
The patient became hypotensive requiring resuscitation with blood products and IV fluids. On arrival to our facility, she had tachycardia, severe abdominal pain, and dark blood on digital rectal exam. We proceeded emergently to the OR.

Results/Outcomes: A sigmoidoscopy was first performed. Visualization was challenging due to copious old blood, however patches of ischemic rectal mucosa with possible necrosis were seen. On diagnostic laparoscopy, she was found to have moderate hemoperitoneum within the pelvis. A segment of necrosis and perforation was identified at the right lateral rectosigmoid junction extending to the mid rectum. Intraperitoneal bleeding was found originating at the site of perforation. After conversion to exploratory laparotomy, a low anterior resection with end colostomy was performed. Findings were consistent with perforated stercoral proctitis with intraperitoneal and intraluminal bleeding from the site of perforation. The patient recovered well postoperatively and had appropriate ostomy function.

Conclusion/Discussion: As with other etiologies of colonic perforation, stercoral perforation has a fairly predictable presentation with severe abdominal pain and signs of sepsis. Classic CT scan findings include pericolonic fat stranding, perfusion defects, and wall thickening, with fecal impaction seen in the vast majority of cases. Though lower GI bleed is a known complication of stercoral ulcers and has been seen with stercoral perforation, hemoperitoneum has not previously been reported as a presenting symptom. Most commonly discussed colonic etiologies of hemoperitoneum include iatrogenic injury, particularly associated with colonoscopies, and recent trauma.

This is a case of stercoral perforation presenting with hemoperitoneum and hematochezia. Stercoral colitis is generally an indolent diagnosis and bleeding is usually self-limited. Symptoms of an intraabdominal bleed may be masked in the setting of a lower GI bleed, thus delaying recognition of continued blood loss. If the clinical picture shows evidence of hypovolemic shock, intraabdominal bleeding should be considered in stercoral perforation.