Surgery Today Jpn. J. Surg. (1992) 22:461-463
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SURGERYTODAY © Springer-Verlag 1992
Stercoraceous Perforation of the Sigmoid Colon: Report of Two Cases SABUROMURAKAMI,HIROTOKAWAHARA,KAZUYUKIKOZIMA,HEISHUNTEI, SHIGERUYASUDA,TAKAYANAKAMURA, and YOSHIOMISHIMA The SecondDepartmentof Surgery,TokyoMedicaland DentalUniversity,1-5-45Yushima,Bunkyo-kuTokyo,113Japan
Abstract: Stercoraceous perforation of the sigmoid colon has rarely been reported in the literature. This lesion is assumed to be produced by the pressure from a hard scybalum resulting in a perforated ulcer with necrotic edges. Two cases of stercoraceous perforation of the sigmoid colon are presented in this paper. It is difficult to diagnose this lesion preoperatively, although ultrasonograms proved useful in showing the colon perforation. This lesion should always be suspected when a patient who has had chronic constipation presents with sudden severe abdominal pain. It is possible that this lesion is becoming more common as the mean age of the population increases and we stress the importance of immediate surgery and intensive care for improving the prognosis. Key Words:
stercoraceous perforation, sigmoid colon,
scybala
Introduction
Although documentation of stercoraceous perforation of the sigmoid colon is rare, the actual incidence of this lesion is thought to be possibly much higher according to the increase in the mean age of the population. This lesion requires emergency surgery to improve the relatively poor prognosis and therefore, we should not overlook the possibility of this lesion when a patient having a long history of chronic constipation is admitted with the suddeha~onset of severe abdominal pain. We report herein two cases of stercoraceous perforation of the sigmoid colon, in one of whom ultrasonograms proved especially valuable in establishing the diagnosis of colon perforation.
Case 1
A 64-year-old woman was admitted with severe lower abdominal pain of sudden onset. She had experienced episodes of constipation for over 20 years and been dialyzed for 2 years because of chronic renal failure. Her abdomen was diffusely rigid and tender with marked muscle guarding. A plain roentgenogram of the abdomen showed free air in the peritoneal cavity (Fig. 1). On physiological examination, her temperature was 37.3°C, pulse rate 108/min, and blood pressure 80/40mmHg. Examination of the peripheral blood revealed a hemoglobin of 12.6 g/100 ml and a leukocyte count of 1300cells/mm 3. Results of other laboratory examinations were within normal limits. Fourteen hours following the onset of abdominal pain, an emergency operation was performed based on the preoperative diagnosis of stomach or bowel perforation. Laparotomy revealed an ovoid perforation of the sigmoid colon at the antimesenteric border with inflammatory and necrotic edges. There was diffuse fecal peritonitis in the peritoneal cavity and scybala in the entire colon, but no diverticulosis or diverticulitis. Resection of the sigmoid colon was done and a colostomy was made in the left'lower abdomen (Hartmann procedure), followed by massive lavage with 10,000 ml physiological saline solution. However, the patient died of circulatory failure a few hours after the operation. Surgical specimens of the sigmoid colon presented a round perforation with inflammatory necrotic edges (Fig. 2).
Case 2
Reprint requests to: S. Murakami (Received for publication on Jan. 7, 1991; accepted on Sep. 13, 1991).
A 76-year-old woman with a 20-year history of chronic constipation was admitted with severe abdominal pain. Her lower abdomen was diffusely rigid and tender with marked muscle guarding. On physiological examina-
462
S. Murakami et al.: Stercoraceous Perforation of the Sigmoid Colon
Fig. 1. A plain roentgenogram of the abdomen of case I. Free air and a large number of scybala were recognized
Fig. 2. Surgical specimen of the sigmoid colon of case 1. A round perforation with inflammatory necrotic edges is seen at the antimesenteric border
tion, her temperature was 36.5°C, pulse rate 92/min, and blood pressure 98/60mmHg. Examination of the peripheral blood revealed hemoglobin levels of 10.8 g/ 100 ml and a leukocyte count of 2300 cells/mm 3. Results
Fig. 3. A plain roentgenogram of the abdomen of case 2. There were a large number of scybala but no free air
of other laboratory examinations were within normal limits. A plain roentogenogram of the abdomen did not show free air in the peritoneal cavity (Fig. 3) but an ultrasonogram revealed echo free space in the right infrahepatic area (Fig. 4). Seven hours following the onset of abdominal pain, an emergency operation was performed, based on the diagnosis of panperitonitis. Laparotomy revealed a round perforation of the sigmoid colon at the antimesenteric border with inflammatory and necrotic edges. There was diffuse bloody and fecal peritonitis in the whole peritoneal cavity and scybala in the colon, but no diverticulosis. Exteriorization of the perforated segment of the sigmoid colon was undertaken and an artificial anus made in the left lower abdomen, followed by massive lavage with 15,000ml physiological saline solution. The patient had a stormy postoperative course complicated by septic shock, cardiac decompensation, and respiratory insufficiency. However, these complications were successfully treated with intensive care and the patient recovered.
S. Murakami et al.: Stercoraceous Perforation of the Sigmoid Colon
Fig. 4. Ultrasonogram of the abdomen of case 2. Free echo space can be seen in the infrahepatic space
Discussion Stercoraceous perforation is defined as a lesion produced by the pressure from a hard stercoroma resulting in a perforated ulcer with necrotic and inflammatory edges.~ Shatila and his associates found only 30 cases reported in the literature up until 1977, 2 however, the actual incidence of this lesion is thought to be probably much more c o m m o n than suggested by the small n u m b e r of case reports. 3"4 A roentgenogram of the a b d o m e n showed free air in the peritoneal cavity only in case 1 of this report, although, a large n u m b e r of scybala were found on the roentgenograms of both patients. Ultrasonogram presented echo free space in the infrahepatic area of case 2, which p r o m o t e d us to perform an immediate operation. Therefore, even in a case where no free air is seen in the peritoneal cavity on a plain roentgenogram, an ultrasonogram is r e c o m m e n d e d to ascertain whether or not there is colon perforation. The surgical specimen from the sigmoid colon of case 1 revealed a round perforation with inflammatory necrotic edges which is regarded as a special feature of this lesion. 5 We also observed the same lesion in the
463
sigmoid colon of case 2. Nevertheless, it is difficult to correctly diagnose stercoraceous perforation preoperatively. There were no characteristic predisposing clues to account for this lesion other than a long history of chronic constipation, followed by a sudden onset of severe abdominal pain. The surgeon should therefore be alerted to the possibility of this type of lesion when considering the differential diagnosis in a patient with severe abdominal pain of sudden onset following a long history of chronic constipation. The only treatment for stercoraceous perforation of the colon is surgical, with exteriozation of the perforated segment of colon being strongly r e c o m m e n d e d whenever possible. 6'7 However, when this procedure is not possible, primary closure of the perforation with a proximal colostomy may be acceptable. Primary resection of the perforated segment of the colon with a proximal colostomy is another alternative, depending upon the patient's condition. F r o m our experience, we conclude that to shorten the time from admission to operation, keeping this lesion in mind is of utmost importance together with sufficient massive lavage of the peritoneal cavity for preventing severe sepsis, Appropriate intensive care is also essential for improving the rather poor prognosis of patients with this lesion.
References 1. Anderson W (1968) Pathology for the surgeon, 8th edn, WB Saunders, Philadelphia, p 284 2. Shatila AH, Ackerman NB (1977) Stercoraceous perforation of the colon: Report of cases and survey of the literature. Dis Colon Rectum 20:524-527 3. Senga S, Kunito S, Katagiri Y, Yamauchi H, Ozeki Y, Hayashi M, Onitsuka A, Ikeda Y (1989) A case of stercoraceous perforation of the sigmoid colon (in Japanese) Shokakigeka (GastroEnterol Surg) 12:1365-1367 4. Yamasbita M, Higa T, Takeshita M, Henzan H, Toyama K, Ishihara M, Kunishima N, Tamaki M (1987) Stercoraceous perforation of the sigmoid colon (in Japanese) Nippon Kynkynigakukaizasshi (Jap J Acute Med) 11:773-775 5. Huttunen R, Heikkinen E, Larmi TKI (1975) Stercoraceous and idiopatic perforations of the colon. Surg Gynecol Obestet 140: 756-760 6. Lasser A, Conte M, Solitare GB (1975) Stercoraceous perforation of the cecum. Dis Colon Rectum 18:410-412 7. Liedberg G (1969) Stercoraceous perforation of the colon. Acta Chit Scand 135:552-554
@
SURGERYTODAY © Springer-Verlag 1992
Stercoraceous Perforation of the Sigmoid Colon: Report of Two Cases SABUROMURAKAMI,HIROTOKAWAHARA,KAZUYUKIKOZIMA,HEISHUNTEI, SHIGERUYASUDA,TAKAYANAKAMURA, and YOSHIOMISHIMA The SecondDepartmentof Surgery,TokyoMedicaland DentalUniversity,1-5-45Yushima,Bunkyo-kuTokyo,113Japan
Abstract: Stercoraceous perforation of the sigmoid colon has rarely been reported in the literature. This lesion is assumed to be produced by the pressure from a hard scybalum resulting in a perforated ulcer with necrotic edges. Two cases of stercoraceous perforation of the sigmoid colon are presented in this paper. It is difficult to diagnose this lesion preoperatively, although ultrasonograms proved useful in showing the colon perforation. This lesion should always be suspected when a patient who has had chronic constipation presents with sudden severe abdominal pain. It is possible that this lesion is becoming more common as the mean age of the population increases and we stress the importance of immediate surgery and intensive care for improving the prognosis. Key Words:
stercoraceous perforation, sigmoid colon,
scybala
Introduction
Although documentation of stercoraceous perforation of the sigmoid colon is rare, the actual incidence of this lesion is thought to be possibly much higher according to the increase in the mean age of the population. This lesion requires emergency surgery to improve the relatively poor prognosis and therefore, we should not overlook the possibility of this lesion when a patient having a long history of chronic constipation is admitted with the suddeha~onset of severe abdominal pain. We report herein two cases of stercoraceous perforation of the sigmoid colon, in one of whom ultrasonograms proved especially valuable in establishing the diagnosis of colon perforation.
Case 1
A 64-year-old woman was admitted with severe lower abdominal pain of sudden onset. She had experienced episodes of constipation for over 20 years and been dialyzed for 2 years because of chronic renal failure. Her abdomen was diffusely rigid and tender with marked muscle guarding. A plain roentgenogram of the abdomen showed free air in the peritoneal cavity (Fig. 1). On physiological examination, her temperature was 37.3°C, pulse rate 108/min, and blood pressure 80/40mmHg. Examination of the peripheral blood revealed a hemoglobin of 12.6 g/100 ml and a leukocyte count of 1300cells/mm 3. Results of other laboratory examinations were within normal limits. Fourteen hours following the onset of abdominal pain, an emergency operation was performed based on the preoperative diagnosis of stomach or bowel perforation. Laparotomy revealed an ovoid perforation of the sigmoid colon at the antimesenteric border with inflammatory and necrotic edges. There was diffuse fecal peritonitis in the peritoneal cavity and scybala in the entire colon, but no diverticulosis or diverticulitis. Resection of the sigmoid colon was done and a colostomy was made in the left'lower abdomen (Hartmann procedure), followed by massive lavage with 10,000 ml physiological saline solution. However, the patient died of circulatory failure a few hours after the operation. Surgical specimens of the sigmoid colon presented a round perforation with inflammatory necrotic edges (Fig. 2).
Case 2
Reprint requests to: S. Murakami (Received for publication on Jan. 7, 1991; accepted on Sep. 13, 1991).
A 76-year-old woman with a 20-year history of chronic constipation was admitted with severe abdominal pain. Her lower abdomen was diffusely rigid and tender with marked muscle guarding. On physiological examina-
462
S. Murakami et al.: Stercoraceous Perforation of the Sigmoid Colon
Fig. 1. A plain roentgenogram of the abdomen of case I. Free air and a large number of scybala were recognized
Fig. 2. Surgical specimen of the sigmoid colon of case 1. A round perforation with inflammatory necrotic edges is seen at the antimesenteric border
tion, her temperature was 36.5°C, pulse rate 92/min, and blood pressure 98/60mmHg. Examination of the peripheral blood revealed hemoglobin levels of 10.8 g/ 100 ml and a leukocyte count of 2300 cells/mm 3. Results
Fig. 3. A plain roentgenogram of the abdomen of case 2. There were a large number of scybala but no free air
of other laboratory examinations were within normal limits. A plain roentogenogram of the abdomen did not show free air in the peritoneal cavity (Fig. 3) but an ultrasonogram revealed echo free space in the right infrahepatic area (Fig. 4). Seven hours following the onset of abdominal pain, an emergency operation was performed, based on the diagnosis of panperitonitis. Laparotomy revealed a round perforation of the sigmoid colon at the antimesenteric border with inflammatory and necrotic edges. There was diffuse bloody and fecal peritonitis in the whole peritoneal cavity and scybala in the colon, but no diverticulosis. Exteriorization of the perforated segment of the sigmoid colon was undertaken and an artificial anus made in the left lower abdomen, followed by massive lavage with 15,000ml physiological saline solution. The patient had a stormy postoperative course complicated by septic shock, cardiac decompensation, and respiratory insufficiency. However, these complications were successfully treated with intensive care and the patient recovered.
S. Murakami et al.: Stercoraceous Perforation of the Sigmoid Colon
Fig. 4. Ultrasonogram of the abdomen of case 2. Free echo space can be seen in the infrahepatic space
Discussion Stercoraceous perforation is defined as a lesion produced by the pressure from a hard stercoroma resulting in a perforated ulcer with necrotic and inflammatory edges.~ Shatila and his associates found only 30 cases reported in the literature up until 1977, 2 however, the actual incidence of this lesion is thought to be probably much more c o m m o n than suggested by the small n u m b e r of case reports. 3"4 A roentgenogram of the a b d o m e n showed free air in the peritoneal cavity only in case 1 of this report, although, a large n u m b e r of scybala were found on the roentgenograms of both patients. Ultrasonogram presented echo free space in the infrahepatic area of case 2, which p r o m o t e d us to perform an immediate operation. Therefore, even in a case where no free air is seen in the peritoneal cavity on a plain roentgenogram, an ultrasonogram is r e c o m m e n d e d to ascertain whether or not there is colon perforation. The surgical specimen from the sigmoid colon of case 1 revealed a round perforation with inflammatory necrotic edges which is regarded as a special feature of this lesion. 5 We also observed the same lesion in the
463
sigmoid colon of case 2. Nevertheless, it is difficult to correctly diagnose stercoraceous perforation preoperatively. There were no characteristic predisposing clues to account for this lesion other than a long history of chronic constipation, followed by a sudden onset of severe abdominal pain. The surgeon should therefore be alerted to the possibility of this type of lesion when considering the differential diagnosis in a patient with severe abdominal pain of sudden onset following a long history of chronic constipation. The only treatment for stercoraceous perforation of the colon is surgical, with exteriozation of the perforated segment of colon being strongly r e c o m m e n d e d whenever possible. 6'7 However, when this procedure is not possible, primary closure of the perforation with a proximal colostomy may be acceptable. Primary resection of the perforated segment of the colon with a proximal colostomy is another alternative, depending upon the patient's condition. F r o m our experience, we conclude that to shorten the time from admission to operation, keeping this lesion in mind is of utmost importance together with sufficient massive lavage of the peritoneal cavity for preventing severe sepsis, Appropriate intensive care is also essential for improving the rather poor prognosis of patients with this lesion.
References 1. Anderson W (1968) Pathology for the surgeon, 8th edn, WB Saunders, Philadelphia, p 284 2. Shatila AH, Ackerman NB (1977) Stercoraceous perforation of the colon: Report of cases and survey of the literature. Dis Colon Rectum 20:524-527 3. Senga S, Kunito S, Katagiri Y, Yamauchi H, Ozeki Y, Hayashi M, Onitsuka A, Ikeda Y (1989) A case of stercoraceous perforation of the sigmoid colon (in Japanese) Shokakigeka (GastroEnterol Surg) 12:1365-1367 4. Yamasbita M, Higa T, Takeshita M, Henzan H, Toyama K, Ishihara M, Kunishima N, Tamaki M (1987) Stercoraceous perforation of the sigmoid colon (in Japanese) Nippon Kynkynigakukaizasshi (Jap J Acute Med) 11:773-775 5. Huttunen R, Heikkinen E, Larmi TKI (1975) Stercoraceous and idiopatic perforations of the colon. Surg Gynecol Obestet 140: 756-760 6. Lasser A, Conte M, Solitare GB (1975) Stercoraceous perforation of the cecum. Dis Colon Rectum 18:410-412 7. Liedberg G (1969) Stercoraceous perforation of the colon. Acta Chit Scand 135:552-554
