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Case presentation
2008-04-18R1 이진영
Case
이 @ 윤 66/M
Present illness
Chronic constipation hx.
최근 1 주일간 defecation 하지 못함 .
내원 3 일 전부터 epigastric discomfort.
내원 전일 abrupt periumbilical sever pain. Plain abdomen x-ray 상 free air 소견보여 transfer.
4cm perforation at cecum, antemesenteric side No intraluminal lesion No tumorous lesion Cecum and ascending
colon adhesion with inflammatory appearance with dirty material.
Mucosa unremarkable
Pathology
Microscopic
Stercoral colitis
Definition Inflammatory process of colonic wall
related to fecal impaction
Main causative factor : Severe chronic constipationelderly : often live in nursing homes
young patients : neurologically impaired
slow transit time : opiates, tricyclic antidepressants, tranquilizers
Stercoral colitisMechanism
Conglomeration of dehydrated fecal material
→ Increased intraluminal pressure
→ Decreases blood supply
→ Ischemia → ulceration and perforation
NeverthelessStercoral ulceration does not always occur among constipation cases
Not every stercoral ulceration results in colon perforation.
Stercoral colitis
Stercoral ulceration:
M/C in antimesenteric aspect of sigmoid colon hypoperfusive status
decreasing water content in the stool
narrow diameter
high intraluminal pressures
CT FindingUncomplicated
fecal impaction
Stranding of pericolonic fat
Presence of -extraluminal bubbles of gas -abscess
DiagnosisHystory of chronic constipation or fecal impaction Intraoperative findings
generalized peritonitis, colonic dilatationcolonic perforation size 1 cm or moreulcerations on the antimesenteric border If frank perforation occurs
-> fecal material within the peritoneal cavity in close proximity to the perforation site
Histologytransmural necrosisulcer margins sharply demarcated nonspecific inflammatory changes no additional colonic pathology is found
TreatmentMost cases of uncomplicated stercoral colitis
successfully treated with disimpaction
Stercoral perforation broad spectrum antibiotics : initiated in all the patient
resection of the colon segment with an end colostomy
primary repair
Underlying disease Tx
Mortality related to stercoral perforation
: 30% to 55% , prompt exploration may decrease that rate
Reference
Stercoral Colitis Leading to Fatal Peritonitis: CT Findings Cathleen et al.
AJR 2005; 184:1189-1193
Management of patients with stercoral perforation of the sigmoid colon: Report of five cases Wen-Shih Huang et al.
World J Gastroenterol 2006 January 21;12(3):500-503
Image of the Month—Perforated Stercoral Ulcer Arch Surg. 2007;142(1):98