Stercoraceous Perforation of the Cecum: Report of Two Cases* ABaAHAM LASSO:R, M . D . , PH.D., MARIO CONTE, M . D . , GILBERT B. SOL1TAm~, M . D .
From the Departments oJ Pathology and Surgery, Hospital o] Saint Raphael, New Haven, Connecticut
STERCORACEOUS PERFORATION
colectomy with an ileotransverse colostomy with end-to-end anastomosis on May 21, 1974. The surgical specimen consisted of 20 cm of terminal ileum and 12 cm of cecum and ascending colon. External examination of the anterior wall of the cecum disclosed a 6-cm firm mass, bulging on the surface and covered by a patchy fibrinoid exudate. On opening the bowel, an nicer with irregular borders, measuring i cm in major diameter and leading into the adjacent mass, was found on the anterior wall of the cecum. Sectioning disclosed that the mass was composed of a cavity containing a fecalith, 2 cm in diameter, and surrounded by necrotic, inflammatory and fibrous tissue (Fig. 1). On microscopic examination the area of ulceration was sharply demarcated from the adjacent colonic mucosa and was composed of granulation tissue and acute and chronic inflammation that extended into the periserosal fat with abundant lipophages, fatty necrosis, and fibrosis. Many small fecal masses were found in the areas of penetration into the bowel wall and periserosal fat. The patient had an uneventful postoperative recovery, was discharged from the hospital on June 1, 1974, and is free of symptoms at the present time.
is defined
b y B o y d 1 as p r o d u c e d by p r e s s u r e f r o m a h a r d , scybalous mass that collects m o s t often i n t h e l a r g e i n t e s t i n e . I t is o n e o f t h e less common
c o n d i t i o n s l e a d i n g to p e r f o r a t i o n
of t h e c o l o n . R e v i e w o f t h e l i t e r a t u r e rev e a l s 25 cases o f s t e r c o r a l u l c e r a t i o n a n d / o r p e r f o r a t i o n of t h e colon.2-~0 O n l y [ o u r of these o c c u r r e d i n the cecum or a s c e n d i n g c o l o n , ; , s, t0 a n d a]l f o u r w e r e f o u n d p o s t mortem. W e r e p o r t h e r e t h e cases of t w o p a t i e n t ~ who had cecum
stercoraceous perforation
treated
surgically,
with
of t h e
conlplete
recovery. Report
of Two
Cases
Patient 1: A 56-year-old Caucasian woman was hospitalized on May 16, 1974, because of pain in the right lower quadrant of two days' duration. Her past medical history included essential hypertension, treated with Enduronyl. She also was taking ferrous sulfate (Feosol). An appendectomy had been done when the patient was 33 years old and she had had a hysterectomy with bilateral salpingooophorectomy for uterine leiomyomas a year prior to the present admission. There was no history of chronic constipation. On physical examination a mass the size of an orange was palpated in the right lower quadrant of the abdomen, which was tender without rigidity. The temperature was 100 F, pulse rate 92/min, blood pressure 180/80 mm Hg. Examination of peripheral blood revealed a hemoglobin of 11.5 g/100 ml and a leukocyte count of 12,300 cells/mm3, with 72 per cent neutrophils. A barium-enema study disclosed changes interpreted as consistent with carcinoma of the cecum. Results of other laboratory examinations were within normal limits. The patient underwent a right hemi-
Patient 2: A 51-year-old Caucasian man was hospitalized on June 17, 1974, because of intermittent sharp pain in the right lower quadrant of one week's duration. There was no history of constipation, and he was taking no medication. On admission, the temperature was 99.6F, pulse rate 100/min, blood pressure 130/100 mm Hg. Physical examination revealed localized tenderness in the right lower quadrant of the abdomen, and a poorly defined mass was palpated. Examination of peripheral blood showed a hemoglobin of 15.5 g/100 ml and 13,100 leukocytes]mm3, with 74 per cent neutrophils. A plain roentgenogram of the abdomen revealed no evidence of obstruction or perforation. Results of all other laboratory examinations were within normal limits. The patient underwent exploratory laparotomy, which disclosed a 4-cm mass in the region of the ileocecal valve. An appendectomy and a limited right hemicolectomy with endto-end ileocolonic anastomosis were done. The surgical specimen consisted of the appendix, which was unremarkable on gross and microscopic examination, and 12 cm of bowel, composed of 5 cm of distal ileum and 7 cm of proximal colon. On ex-
* Received for publication November 15, 1974. Address reprint requests to Dr. Lasser, 36 Whitney Lane, Orange, Connecticut 06477. 410 Dis. Col. & Reet.
July-Aug. 1975
Volume 18 Number 5
Volume 18 Number 5
STERCORACEOUS PERFORATION
OF THE
CECUM
411
Fro. 1. Section of paracecal mass adjacent to the ileocecal valve, showing the fecalith and the cavity surrounded by fibroadipose tissue, ternal examination there was a 4-cm, firm mass on the anterolateral side of the cecum near the ileocecal valve, covered by glistening, congested serosa. Opening the colon disclosed an irregular ulcer, 1.5 cm in diameter, in the anterolateral wall of the cecum. The ulcer led into the aforedescribed mass, which contained a 2-cm fecalith surrounded by necrotic tissue (Fig. 2). The microscopic appearance was similar to that in the case of Patient t. The patient was discharged from the hospital June 27, 1974, and remains free o[ symptoms at the present time. Discussion
Factors that predispose to the f o r m a t i o n of fecalomas i n c l u d e mechanical obstruction, m e g a c o l o n , a foreign b o d y or g a l l s t o n e that becomes the n i d u s of the fecaloma, decreased m u c u s p r o d u c t i o n , previous b a r i u m e n e m a e x a m i n a t i o n , strictures f o l l o w i n g i n f l a m m a t o r y disease of the colon, treatm e n t w i t h drugs k n o w n to p r o d u c e cons t i p a t i o n (such as tranquilizers, especially in m e n t a l p a t i e n t s ) , a n d p r o l o n g e d b e d rest with p o o r bowel habits. B l o m e r 3 r e p o r t e d a case of p e r f o r a t i o n of the cecum caused by a fecalith t r a p p e d in a cecal h a u s t r a t i o n . H e stated that the haustrations, folds a n d valvulae of the cecum m a k e the a n a t o m i c
structure of this o r g a n , in certain individuals, of such a c h a r a c t e r as to favor the t r a p p i n g of [ecaliths. N o n e of these factors was identified in o u r patients. I n the two cases r e p o r t e d here, each pat i e n t h a d a mass in the r i g h t lower q u a d r a n t of the a b d o m e n , w h i c h clinically was difficult to d i f f e r e n t i a t e f r o m a m a l i g n a n c y of the cecum. I n b o t h cases there were no inspissated h a r d fecal masses d i s t e n d i n g the i n t e s t i n a l l u m e n , a n d there was n o obs t r u c t i o n of the bowel. Bowel f u n c t i o n was n o r m a l in both p a t i e n t s . I n all cases p r e v i o u s l y r e p o r t e d in the l i t e r a t u r e , except four, 3, s, ~0 the u l c e r a t i o n a n d p e r f o r a t i o n o c c u r r e d in the r e c t u m or sigmoid. T h e r e are several possible explan a t i o n s [or the g r e a t e r frequency of stercoraceous u l c e r a t i o n a n d p e r f o r a t i o n of the left colon: the pressure of s u r r o u n d i n g structures does n o t p e r m i t a d e q u a t e dist e n t i o n of the r e c t o s i g m o i d ; fecal m a t e r i a l is of a h a r d e r consistency in the left colon; a n d the l u m e n of the bowel in the r e g i o n of the r e c t o s i g m o i d is m u c h n a r r o w e r t h a n t h a t of the r i g h t colon.
412
LASSER, ET AL.
Dis. CoL &Reet.
July-Aug, 1975
FIG. 2. Cecal mucosa, showing fecalith at the base of the ulceration. Note the sharp and irregular borders of the ulcer.
I n b o t h cases the ulcers were single, w i t h irregular geographic outlines and sharp d e m a r c a t i o n between the m a r g i n s of ulceration a n d the a d j a c e n t mucosa. T h e perforation Occurred in the c e n t r a l p o r t i o n of the u l c e r a t i o n , which c o n t a i n e d small fragm e n t s of fecal m a t e r i a l . T h e gross a n d microscopic a p p e a r a n c e , a l t h o u g h n o t pat h o g n o m o n i c of a specific lesion, is consistently p r e s e n t in u l c e r a t i o n s d u e to stercoraceous m a t e r i a l . T h e obvious a p p r o a c h to these lesions is early surgical t r e a t m e n t in order to a v o i d fecal peritonitis. T h e s e cases s h o u l d a l e r t the surgeon a n d the p a t h o l o g i s t to the possibility of this type of lesion when considering the d i f f e r e n t i a l diagnosis in a p a t i e n t with a b d o m i n a l p a i n a n d a mass in the right lower quadrant. Summary T w o cases of stercoraceous p e r f o r a t i o n of the cecum with a d j a c e n t mass f o r m a t i o n s i m u l a t i n g a n e o p l a s m are described. T h e p r e d i s p o s i n g factors for the f o r m a t i o n of fecalomas a n d the m e c h a n i s m s of perforation are discussed a n d a review of the lite r a t u r e on this subject is presented. T h e r e
were no d e m o n s t r a b l e p r e d i s p o s i n g colonic lesions to account for the fecaloma format i o n in these cases. B o t h p a t i e n t s recovered c o m p l e t e l y after surgical t r e a t m e n t of the lesions. References 1. Anderson W: Boyd's Pathology for the Surgeon. Ed. 8. Philadelphia, W. B. Saunders, 1967, p 284 2. Bauer JJ, Weiss M, Dreiling DA: Stercoraceous Am 52: 1047, 1972 perforation of the colon. Surg Clin North 3. Blotner C: Trapped fecalith in cecal haustration with local necrosis. Am J Surg 76: 446, 1948 4. Castleton KB: Idiopathic perforation of the colon. Am Surg 28: 329, 1962 5. Grinvalsky HT, Bowerman CI: Stercoraceous ulcers of the colon: Relatively neglected medical and surgical problems. JAMA 171: 1941, 1959 6. Lal S, Brown GN: Some unusual complications of fecal impaction. Am J Proctol t8: 226, 1967 7. Liedberg G: Stercoraceous perforation of the colon: Case report. Acta Chir Scand 135:552, 1969 8. Lyon DC, Sheiner HJ: Idiopathic rectosigmoid perforation. Surg Gynecol Obstet 128: 991, 1969 9. Printz JH, Hoffman JS, Khazei H: Multiple stercoraceous ulcers of the colon associated with huge fecalomas and perforation: Case report. Am Surg 27: 714, 1961 10. Smith KE: Perforation of stercoraceous ulceration of the colon. J Maine Med Assoc 56: 183, 1965
From the Departments oJ Pathology and Surgery, Hospital o] Saint Raphael, New Haven, Connecticut
STERCORACEOUS PERFORATION
colectomy with an ileotransverse colostomy with end-to-end anastomosis on May 21, 1974. The surgical specimen consisted of 20 cm of terminal ileum and 12 cm of cecum and ascending colon. External examination of the anterior wall of the cecum disclosed a 6-cm firm mass, bulging on the surface and covered by a patchy fibrinoid exudate. On opening the bowel, an nicer with irregular borders, measuring i cm in major diameter and leading into the adjacent mass, was found on the anterior wall of the cecum. Sectioning disclosed that the mass was composed of a cavity containing a fecalith, 2 cm in diameter, and surrounded by necrotic, inflammatory and fibrous tissue (Fig. 1). On microscopic examination the area of ulceration was sharply demarcated from the adjacent colonic mucosa and was composed of granulation tissue and acute and chronic inflammation that extended into the periserosal fat with abundant lipophages, fatty necrosis, and fibrosis. Many small fecal masses were found in the areas of penetration into the bowel wall and periserosal fat. The patient had an uneventful postoperative recovery, was discharged from the hospital on June 1, 1974, and is free of symptoms at the present time.
is defined
b y B o y d 1 as p r o d u c e d by p r e s s u r e f r o m a h a r d , scybalous mass that collects m o s t often i n t h e l a r g e i n t e s t i n e . I t is o n e o f t h e less common
c o n d i t i o n s l e a d i n g to p e r f o r a t i o n
of t h e c o l o n . R e v i e w o f t h e l i t e r a t u r e rev e a l s 25 cases o f s t e r c o r a l u l c e r a t i o n a n d / o r p e r f o r a t i o n of t h e colon.2-~0 O n l y [ o u r of these o c c u r r e d i n the cecum or a s c e n d i n g c o l o n , ; , s, t0 a n d a]l f o u r w e r e f o u n d p o s t mortem. W e r e p o r t h e r e t h e cases of t w o p a t i e n t ~ who had cecum
stercoraceous perforation
treated
surgically,
with
of t h e
conlplete
recovery. Report
of Two
Cases
Patient 1: A 56-year-old Caucasian woman was hospitalized on May 16, 1974, because of pain in the right lower quadrant of two days' duration. Her past medical history included essential hypertension, treated with Enduronyl. She also was taking ferrous sulfate (Feosol). An appendectomy had been done when the patient was 33 years old and she had had a hysterectomy with bilateral salpingooophorectomy for uterine leiomyomas a year prior to the present admission. There was no history of chronic constipation. On physical examination a mass the size of an orange was palpated in the right lower quadrant of the abdomen, which was tender without rigidity. The temperature was 100 F, pulse rate 92/min, blood pressure 180/80 mm Hg. Examination of peripheral blood revealed a hemoglobin of 11.5 g/100 ml and a leukocyte count of 12,300 cells/mm3, with 72 per cent neutrophils. A barium-enema study disclosed changes interpreted as consistent with carcinoma of the cecum. Results of other laboratory examinations were within normal limits. The patient underwent a right hemi-
Patient 2: A 51-year-old Caucasian man was hospitalized on June 17, 1974, because of intermittent sharp pain in the right lower quadrant of one week's duration. There was no history of constipation, and he was taking no medication. On admission, the temperature was 99.6F, pulse rate 100/min, blood pressure 130/100 mm Hg. Physical examination revealed localized tenderness in the right lower quadrant of the abdomen, and a poorly defined mass was palpated. Examination of peripheral blood showed a hemoglobin of 15.5 g/100 ml and 13,100 leukocytes]mm3, with 74 per cent neutrophils. A plain roentgenogram of the abdomen revealed no evidence of obstruction or perforation. Results of all other laboratory examinations were within normal limits. The patient underwent exploratory laparotomy, which disclosed a 4-cm mass in the region of the ileocecal valve. An appendectomy and a limited right hemicolectomy with endto-end ileocolonic anastomosis were done. The surgical specimen consisted of the appendix, which was unremarkable on gross and microscopic examination, and 12 cm of bowel, composed of 5 cm of distal ileum and 7 cm of proximal colon. On ex-
* Received for publication November 15, 1974. Address reprint requests to Dr. Lasser, 36 Whitney Lane, Orange, Connecticut 06477. 410 Dis. Col. & Reet.
July-Aug. 1975
Volume 18 Number 5
Volume 18 Number 5
STERCORACEOUS PERFORATION
OF THE
CECUM
411
Fro. 1. Section of paracecal mass adjacent to the ileocecal valve, showing the fecalith and the cavity surrounded by fibroadipose tissue, ternal examination there was a 4-cm, firm mass on the anterolateral side of the cecum near the ileocecal valve, covered by glistening, congested serosa. Opening the colon disclosed an irregular ulcer, 1.5 cm in diameter, in the anterolateral wall of the cecum. The ulcer led into the aforedescribed mass, which contained a 2-cm fecalith surrounded by necrotic tissue (Fig. 2). The microscopic appearance was similar to that in the case of Patient t. The patient was discharged from the hospital June 27, 1974, and remains free o[ symptoms at the present time. Discussion
Factors that predispose to the f o r m a t i o n of fecalomas i n c l u d e mechanical obstruction, m e g a c o l o n , a foreign b o d y or g a l l s t o n e that becomes the n i d u s of the fecaloma, decreased m u c u s p r o d u c t i o n , previous b a r i u m e n e m a e x a m i n a t i o n , strictures f o l l o w i n g i n f l a m m a t o r y disease of the colon, treatm e n t w i t h drugs k n o w n to p r o d u c e cons t i p a t i o n (such as tranquilizers, especially in m e n t a l p a t i e n t s ) , a n d p r o l o n g e d b e d rest with p o o r bowel habits. B l o m e r 3 r e p o r t e d a case of p e r f o r a t i o n of the cecum caused by a fecalith t r a p p e d in a cecal h a u s t r a t i o n . H e stated that the haustrations, folds a n d valvulae of the cecum m a k e the a n a t o m i c
structure of this o r g a n , in certain individuals, of such a c h a r a c t e r as to favor the t r a p p i n g of [ecaliths. N o n e of these factors was identified in o u r patients. I n the two cases r e p o r t e d here, each pat i e n t h a d a mass in the r i g h t lower q u a d r a n t of the a b d o m e n , w h i c h clinically was difficult to d i f f e r e n t i a t e f r o m a m a l i g n a n c y of the cecum. I n b o t h cases there were no inspissated h a r d fecal masses d i s t e n d i n g the i n t e s t i n a l l u m e n , a n d there was n o obs t r u c t i o n of the bowel. Bowel f u n c t i o n was n o r m a l in both p a t i e n t s . I n all cases p r e v i o u s l y r e p o r t e d in the l i t e r a t u r e , except four, 3, s, ~0 the u l c e r a t i o n a n d p e r f o r a t i o n o c c u r r e d in the r e c t u m or sigmoid. T h e r e are several possible explan a t i o n s [or the g r e a t e r frequency of stercoraceous u l c e r a t i o n a n d p e r f o r a t i o n of the left colon: the pressure of s u r r o u n d i n g structures does n o t p e r m i t a d e q u a t e dist e n t i o n of the r e c t o s i g m o i d ; fecal m a t e r i a l is of a h a r d e r consistency in the left colon; a n d the l u m e n of the bowel in the r e g i o n of the r e c t o s i g m o i d is m u c h n a r r o w e r t h a n t h a t of the r i g h t colon.
412
LASSER, ET AL.
Dis. CoL &Reet.
July-Aug, 1975
FIG. 2. Cecal mucosa, showing fecalith at the base of the ulceration. Note the sharp and irregular borders of the ulcer.
I n b o t h cases the ulcers were single, w i t h irregular geographic outlines and sharp d e m a r c a t i o n between the m a r g i n s of ulceration a n d the a d j a c e n t mucosa. T h e perforation Occurred in the c e n t r a l p o r t i o n of the u l c e r a t i o n , which c o n t a i n e d small fragm e n t s of fecal m a t e r i a l . T h e gross a n d microscopic a p p e a r a n c e , a l t h o u g h n o t pat h o g n o m o n i c of a specific lesion, is consistently p r e s e n t in u l c e r a t i o n s d u e to stercoraceous m a t e r i a l . T h e obvious a p p r o a c h to these lesions is early surgical t r e a t m e n t in order to a v o i d fecal peritonitis. T h e s e cases s h o u l d a l e r t the surgeon a n d the p a t h o l o g i s t to the possibility of this type of lesion when considering the d i f f e r e n t i a l diagnosis in a p a t i e n t with a b d o m i n a l p a i n a n d a mass in the right lower quadrant. Summary T w o cases of stercoraceous p e r f o r a t i o n of the cecum with a d j a c e n t mass f o r m a t i o n s i m u l a t i n g a n e o p l a s m are described. T h e p r e d i s p o s i n g factors for the f o r m a t i o n of fecalomas a n d the m e c h a n i s m s of perforation are discussed a n d a review of the lite r a t u r e on this subject is presented. T h e r e
were no d e m o n s t r a b l e p r e d i s p o s i n g colonic lesions to account for the fecaloma format i o n in these cases. B o t h p a t i e n t s recovered c o m p l e t e l y after surgical t r e a t m e n t of the lesions. References 1. Anderson W: Boyd's Pathology for the Surgeon. Ed. 8. Philadelphia, W. B. Saunders, 1967, p 284 2. Bauer JJ, Weiss M, Dreiling DA: Stercoraceous Am 52: 1047, 1972 perforation of the colon. Surg Clin North 3. Blotner C: Trapped fecalith in cecal haustration with local necrosis. Am J Surg 76: 446, 1948 4. Castleton KB: Idiopathic perforation of the colon. Am Surg 28: 329, 1962 5. Grinvalsky HT, Bowerman CI: Stercoraceous ulcers of the colon: Relatively neglected medical and surgical problems. JAMA 171: 1941, 1959 6. Lal S, Brown GN: Some unusual complications of fecal impaction. Am J Proctol t8: 226, 1967 7. Liedberg G: Stercoraceous perforation of the colon: Case report. Acta Chir Scand 135:552, 1969 8. Lyon DC, Sheiner HJ: Idiopathic rectosigmoid perforation. Surg Gynecol Obstet 128: 991, 1969 9. Printz JH, Hoffman JS, Khazei H: Multiple stercoraceous ulcers of the colon associated with huge fecalomas and perforation: Case report. Am Surg 27: 714, 1961 10. Smith KE: Perforation of stercoraceous ulceration of the colon. J Maine Med Assoc 56: 183, 1965
