Colonic Perforation Secondary to Fecal Impaction: Report
of a C a s e *
SHEN--YE WANG, M.D., t JOHN C. SUTHERLAND, M.D. From the Department of Pathology, University oJ Maryland, and the Baltimore Cancer Research Center, National Cancer Institute, Baltimore, Maryland
One day she was found to be cyanotic, unresponsive, and with a large palpable mass in the left side of the abdomen. On arrival at the hospital she was found to have a temperature of 100F and to be in shock, with a systolic blood pressure of 60 m m Hg. T h e a b d o m e n was markedly distended, silent and tympanitic. T h e blood pressure rose briefly with vasopressor agents, b u t subsequently fell, and she died a few hours after admission. Postmortem examination was restricted by the permit to the abdomen. We found a greatly dilated rectum and sigmoid colon, which were distended with impacted feces forming a mass measuring about l0 • 10 • 20 cm. T h e r e were two perforations in the midportion of the sigmoid colon (Fig. 1). All peritoneal surfaces were covered with fecopurulent material. T h e r e was no other intra-abdominal abnormality that might have contributed to obstruction or perforation.
REPORTS OF spontaneous perforations of the colon as a result of large fecal impactions have been infrequent. In 1972, Bauer et al. 1 were able to collect only 21 cases (called stercoraceous perforations) from the literature, and added four of their own. H u t t u n e n et al., 4 in 1975, reported 14 cases from Finland, and there are other reports of single cases. 2, s, 6 Recently we performed an autopsy on a mentally defective patient whose colon had perforated at the site of a large fecal impaction. Previous series also included mentally defective patients.i, 4 Following this autopsy we wrote to a number of selected hospitals caring for chronically disabled or mentally defective patients. We learned that this complication is well known, at least in some of the responding institutions. Therefore, we feel it is worthwhile to report an autopsy on another mentally defective patient whose colon had perforated at the site of a large fecal impaction.
Reports from Other Hospitals We wrote to superintendents of 13 hospitals (one federal and 12 state) caring for psychiatric and mentally defective patients and received replies from seven. Most of the replies came from pathologists. Pathologists in three hospitals assured us they were aware of similar instances. One reported a single case in 2,500 autopsies. Another had seen two during an 11-year period, and the third assured us there were a number of cases in his files over the past 25 years and several thousand autopsies.
R e p o r t of a Case A 44-year-old woman, described as a spastic paraplegic, unable to feed herself, incontinent of urine, restless and noisy, had lived in a local sanitarium since the age of 3 years. She was considered to have a mental age of approximately 3 months. She received no medication except iron and vitamin supplements and tranquilizers. Particularly, she was not receiving stool softeners or laxatives.
Discussion When perforation occurs as a result of lower colonic obstruction, the site of perforation is usually in the wall of the cecum. T h e cecum has the greater diameter and is thus more easily stretched, according to the law of LaPlace, compared with the remain-
* Received for publication June 9, 1976. ]" Present address: Department of Pathology, Peter Bent Brigham Hospital, Boston, Massachusetts 02115. Address reprint requests to Dr. Sutherland: Dep a r t m e n t of Pathology, University of Maryland, 22 South Greene Street, Baltimore Maryland 21201.
555 Dis. Col. & Rect. May-June, 1977
Volume 20 Number 4
356
WANG AND SUTHERLAND
Dis. Col. & R e c t . May-June. 1977
some neural mechanism, considering that this patient was reported to be paraplegic. Fecal impactions may frequently cause stercoral ulcerations, as demonstrated in a series of 175 unselected autopsies.3 Careful examination of the colon disclosed stercoral ulcers in ten, four of which resulted in perforation and death. Although death frequently follows such perforation, two of the four patients reported by Bauer et al.1 were successfully treated by resecting the entire rectosigmoid and bringing the p r o x i m a l end out as a colostomy. Fecal impactions occur most commonly in patients who are chronically bedridden, for whatever reason. Actual perforation, however, occurs most frequently in those unable to comprehend the source of their discomfort and to communicate effectively with others. References FIG. 1, Feces extruding through one of two perforations in the sigmoid colon just above the peritoneal reflection (arrow).
ing narrower portions of the colon. 7 T h e perforation of the sig-moid colon in our case and other cases is the result of local mechanical compression of the wall of the sigmold colon with ischemic necrosis. Although we were unable to find other intra-abdominal abnormalities that might have caused or at least contributed to either the development of fecal impaction or to perforation, we are unable to rule out the effects of
1. Bauer JJ, Weiss M, Dreiling DA: Stercoraceous perforation of the colon. Surg Clin North Am 52:1047 (Aug) 1972 2. Giacomelli G: Quoted by Raffensperger EC6 3. Grinvalsky HT, Bowerman CI: Stercoraceous ulcers of the colon: Relatively neglected medical and surgical problem. JAMA 171: 1941, 1959 4. Huttunen R, Heikkinen E, Larmi TK: Stercoraceous and idiopathic perforations of the colon. Surg Gynecol Obstet 140: 756, 1975 5. Netto AC: Quoted by Raffensperger EC6 6. Raffensperger EC: Fecal impaction of the colon and rectum. In Bockus HL (ed): Gastroenterology. Ed. 2. Philadelphia, W. B. Saunders, 1964, vol. 2, chapt 78, p 1073 7. Schwartz SI, Storer EH: Manifestations of gastrointestinal disease. In Schwartz SI (ed): Principles of Surgery. Ed. 2. New York, McGraw-Hill, 1974, p 982
of a C a s e *
SHEN--YE WANG, M.D., t JOHN C. SUTHERLAND, M.D. From the Department of Pathology, University oJ Maryland, and the Baltimore Cancer Research Center, National Cancer Institute, Baltimore, Maryland
One day she was found to be cyanotic, unresponsive, and with a large palpable mass in the left side of the abdomen. On arrival at the hospital she was found to have a temperature of 100F and to be in shock, with a systolic blood pressure of 60 m m Hg. T h e a b d o m e n was markedly distended, silent and tympanitic. T h e blood pressure rose briefly with vasopressor agents, b u t subsequently fell, and she died a few hours after admission. Postmortem examination was restricted by the permit to the abdomen. We found a greatly dilated rectum and sigmoid colon, which were distended with impacted feces forming a mass measuring about l0 • 10 • 20 cm. T h e r e were two perforations in the midportion of the sigmoid colon (Fig. 1). All peritoneal surfaces were covered with fecopurulent material. T h e r e was no other intra-abdominal abnormality that might have contributed to obstruction or perforation.
REPORTS OF spontaneous perforations of the colon as a result of large fecal impactions have been infrequent. In 1972, Bauer et al. 1 were able to collect only 21 cases (called stercoraceous perforations) from the literature, and added four of their own. H u t t u n e n et al., 4 in 1975, reported 14 cases from Finland, and there are other reports of single cases. 2, s, 6 Recently we performed an autopsy on a mentally defective patient whose colon had perforated at the site of a large fecal impaction. Previous series also included mentally defective patients.i, 4 Following this autopsy we wrote to a number of selected hospitals caring for chronically disabled or mentally defective patients. We learned that this complication is well known, at least in some of the responding institutions. Therefore, we feel it is worthwhile to report an autopsy on another mentally defective patient whose colon had perforated at the site of a large fecal impaction.
Reports from Other Hospitals We wrote to superintendents of 13 hospitals (one federal and 12 state) caring for psychiatric and mentally defective patients and received replies from seven. Most of the replies came from pathologists. Pathologists in three hospitals assured us they were aware of similar instances. One reported a single case in 2,500 autopsies. Another had seen two during an 11-year period, and the third assured us there were a number of cases in his files over the past 25 years and several thousand autopsies.
R e p o r t of a Case A 44-year-old woman, described as a spastic paraplegic, unable to feed herself, incontinent of urine, restless and noisy, had lived in a local sanitarium since the age of 3 years. She was considered to have a mental age of approximately 3 months. She received no medication except iron and vitamin supplements and tranquilizers. Particularly, she was not receiving stool softeners or laxatives.
Discussion When perforation occurs as a result of lower colonic obstruction, the site of perforation is usually in the wall of the cecum. T h e cecum has the greater diameter and is thus more easily stretched, according to the law of LaPlace, compared with the remain-
* Received for publication June 9, 1976. ]" Present address: Department of Pathology, Peter Bent Brigham Hospital, Boston, Massachusetts 02115. Address reprint requests to Dr. Sutherland: Dep a r t m e n t of Pathology, University of Maryland, 22 South Greene Street, Baltimore Maryland 21201.
555 Dis. Col. & Rect. May-June, 1977
Volume 20 Number 4
356
WANG AND SUTHERLAND
Dis. Col. & R e c t . May-June. 1977
some neural mechanism, considering that this patient was reported to be paraplegic. Fecal impactions may frequently cause stercoral ulcerations, as demonstrated in a series of 175 unselected autopsies.3 Careful examination of the colon disclosed stercoral ulcers in ten, four of which resulted in perforation and death. Although death frequently follows such perforation, two of the four patients reported by Bauer et al.1 were successfully treated by resecting the entire rectosigmoid and bringing the p r o x i m a l end out as a colostomy. Fecal impactions occur most commonly in patients who are chronically bedridden, for whatever reason. Actual perforation, however, occurs most frequently in those unable to comprehend the source of their discomfort and to communicate effectively with others. References FIG. 1, Feces extruding through one of two perforations in the sigmoid colon just above the peritoneal reflection (arrow).
ing narrower portions of the colon. 7 T h e perforation of the sig-moid colon in our case and other cases is the result of local mechanical compression of the wall of the sigmold colon with ischemic necrosis. Although we were unable to find other intra-abdominal abnormalities that might have caused or at least contributed to either the development of fecal impaction or to perforation, we are unable to rule out the effects of
1. Bauer JJ, Weiss M, Dreiling DA: Stercoraceous perforation of the colon. Surg Clin North Am 52:1047 (Aug) 1972 2. Giacomelli G: Quoted by Raffensperger EC6 3. Grinvalsky HT, Bowerman CI: Stercoraceous ulcers of the colon: Relatively neglected medical and surgical problem. JAMA 171: 1941, 1959 4. Huttunen R, Heikkinen E, Larmi TK: Stercoraceous and idiopathic perforations of the colon. Surg Gynecol Obstet 140: 756, 1975 5. Netto AC: Quoted by Raffensperger EC6 6. Raffensperger EC: Fecal impaction of the colon and rectum. In Bockus HL (ed): Gastroenterology. Ed. 2. Philadelphia, W. B. Saunders, 1964, vol. 2, chapt 78, p 1073 7. Schwartz SI, Storer EH: Manifestations of gastrointestinal disease. In Schwartz SI (ed): Principles of Surgery. Ed. 2. New York, McGraw-Hill, 1974, p 982
