Case Report

Massive Fecal Impaction Presenting with Megarectum and Perforation of a Stercoral Ulcer at the Rectosigmoid Junction

Authors: Capt. Jonathan B. Lundy MC,, MD, Thomas R. Gadacz, MD

Abstract

A 25-year-old male with lifelong constipation presented to the emergency department with an acute abdomen. Initial resuscitation was performed, and the patient underwent urgent laparotomy. He was found to have feculent peritonitis with megabowel involving the rectum and sigmoid colon and a stercoral ulcer with full thickness erosion, and perforation was also identified on the anti-mesocolic surface at the rectosigmoid junction. Abdominal irrigation and subtotal colectomy with proximal fecal diversion was performed. This case illustrates that recognition of severe, chronic constipation should lead to interventions including disimpaction and aggressive medical management. When indicated, megabowel can be managed surgically in an elective setting based on anatomic findings and physiologic studies. Peritonitis is an ominous late finding in patients with severe constipation.


Key Points


* Constipation can lead to the catastrophic complications of stercoral ulceration with perforation and megabowel.


* Stercoral ulceration with perforation is an ischemic phenomenon involving impacted stool causing necrosis and erosion through large bowel wall with the majority of patients having underlying chronic constipation.


* Megabowel can be diagnosed and managed conservatively with elective surgical intervention reserved for medical failure.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Grinvalsky HT, Bowerman CI. Stercoraceous ulcers of the colon: relatively neglected medical and surgical problem. JAMA 1959;171:1941–1946.
 
2. Baren JM, Seidel JS. Fecal impaction: a rare cause of respiratory arrest in childhood. Pediatr Emerg Care 1994;10:339–341.
 
3. McWilliams WA, Khauli RB, Zein TA. Ureteral obstruction due to massive fecal impaction. South Med J 1984;77:275–276.
 
4. Hoballah JJ, Chalmers RT, Sharp WJ, et al. Fecal impaction as a cause of acute lower limb ischemia. Am J Gastroenterol 1995;90:2055–2057.
 
5. Lerman BB, Levin ML, Patterson R. Hepatic encephalopathy precipitated by fecal impaction. Arch Intern Med 1979;139:707–708.
 
6. Preston DM, Lennard-Jones JE, Thomas BM. Towards a radiologic definition of idiopathic megacolon.Gastrointest Radiol 1985;10:167–169.
 
7. Maull KI, Kinning WK, Kay S. Stercoral ulceration. Am Surg 1982;48:20–24.
 
8. Patel VG, Kalakuntla V, Fortson JK, et al. Stercoral perforation of the sigmoid colon: report of a rare case and its possible association with nonsteroidal anti-inflammatory drugs. Am Surg 2002;68:62–64.
 
9. Serpell JW, Nicholls RJ. Stercoral perforation of the colon. Br J Surg 1990;77:1325–1329.
 
10. Ó Suilleabhain CB, Anderson JH, McKee RF, et al. Strategy for the surgical management of patients with idiopathic megarectum and megacolon. Br J Surg 2001;88:1392–1396.
 
11. Hosie KB, Kmoit WA, Keighley MR. Constipation: another indication for restorative proctocolectomy. Br J Surg 1990;77:801–802.
 
12. Williams NS, Fajobi OA, Lunniss PJ, et al. Vertical reduction rectoplasty: a new treatment for idiopathic megarectum. Br J Surg 2000;87:1203–1208.
 
13. Apelgren KN, Yuen JC. Distal colonic impaction requiring laparotomy in an adult with cystic fibrosis.J Clin Gastroenterol 1989;1:687–690.
 
14. Lohlun J, Margolis M, Gorecki P, et al. Fecal impaction causing megarectum-producing colorectal catastrophes: a report of two cases. Dig Surg 2000;17:196–198.