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Journal of Pain and Symptom Management
Vol. 50 No. 2 August 2015
Clinical Note
Stercoral Perforation of the Colon: A Potentially Fatal Complication of Opioid-Induced Constipation Andrew Davies, FRCP, and Katherine Webber, PhD Royal Surrey County Hospital, Guildford, Surrey, United Kingdom
Abstract Stercoral perforation of the colon is a rare complication of constipation, and there have only been a few reported cases of stercoral perforation of the colon secondary to opioid-induced constipation. This article describes such a case in a cancer survivor with chronic cancer-related pain and reviews the medical/surgical literature on stercoral perforation of the colon. J Pain Symptom Manage 2015;50:260e262. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Stercoral perforation, opioid analgesics, opioid-induced constipation
Introduction Opioid analgesics are the cornerstone of the management of cancer pain,1 and constipation is a wellrecognized common side effect of this group of drugs.2 Indeed, learned guidelines recommend that patients are co-prescribed appropriate laxatives with opioid analgesics.1,3 Opioids have a number of actions on the gastrointestinal tract;4 opioid-induced constipation is related to a decrease in gastrointestinal motility (small bowel, large bowel), a decrease in small bowel fluid secretion, an increase in large bowel fluid reabsorption, an increase in sphincter tone (ileocecal valve, anal sphincter), and a decrease in anorectal sensitivity.5 Opioid-induced constipation is associated with a variety of physical, psychological, and social consequences.6 Physical symptoms include anorexia, nausea, vomiting, abdominal bloating, and abdominal discomfort/pain; physical complications include fecal impaction, intestinal obstruction, fecal incontinence, hemorrhoids, urinary incontinence, and urinary retention.6,7 Stercoral perforation of the colon is a rare complication of constipation, and there have only been a few reported cases of stercoral perforation of the colon secondary to opioid-induced constipation.8,9 This article describes such a case in a cancer
Address correspondence to: Andrew Davies, FRCP, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK. E-mail: [email protected] Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
survivor with chronic cancer-related pain and reviews the medical/surgical literature on stercoral perforation of the colon.
Case Report The patient was a 67-year-old woman, who had been diagnosed with Stage IV B, diffuse large B-cell lymphoma, and who had achieved a complete response with R-CHOP (rituximab, cyclophosphamide, hydroxydaunomycin, OncovinÒ, prednisone) chemotherapy. She was referred for management of chronic back pain, which was secondary to vertebral collapse (secondary to previous lymphoma). The back pain was controlled with modified-release oxycodone, and she was prescribed laxatives to treat/prevent constipation. Initially she was given a high dose of a macrogol laxative to treat fecal impaction from her previous opioid analgesic. Subsequently, she was given standard doses of senna and sodium docusate to prevent constipation. She reported no further problems with constipation and was assumed to be taking regular laxatives (The patient was repeatedly advised about taking regular laxatives to prevent constipation). A few months after referral, she presented as an emergency with acute abdominal pain. On
Accepted for publication: February 15, 2015.
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2015.02.019
Vol. 50 No. 2 August 2015
Opioid-Induced Stercoral Perforation of the Colon
examination, she had signs of septic shock and generalized peritonitis. A chest X-ray demonstrated free air under the diaphragm (Fig. 1). She was medically stabilized and then underwent an emergency laparotomy. At operation, she was found to have a perforation of the transverse colon, with fecal matter in the peritoneal cavity and colon; the transverse colon was resected, and the peritoneal cavity was thoroughly ‘‘washed out.’’ She was transferred to the intensive care unit for ongoing management of the sepsis and related problems. However, she died from complications of the sepsis five days later. Histology of the resected transverse colon was consistent with a stercoral perforation; there was no evidence of recurrent lymphoma.
Discussion Stercoral perforation has been defined as ‘‘perforation of the bowel due to pressure necrosis from fecal masses.’’8 It is a somewhat ‘‘rare’’ phenomenon, with stercoral perforation of the terminal ileum, cecum and rectum being an even less common phenomenon.8,10,11 Thus, Serpell and Nicholls8 reviewed the literature from 1894 (date of the first recorded case12) to 1990 and identified a total of 64 cases. Similarly, Maurer et al.9 reviewed the literature from 1894 to 1998 and identified a total of 81 cases, although they also reported a further seven cases managed in their unit in the preceding five-year period. It should be noted that the seven cases reported by Maurer et al. represented only 3.2% of patients with perforation of the colon managed in their unit during this time period. Unsurprisingly, the major predisposing factor to stercoral perforation of the colon is the presence of
Fig. 1. Patient’s erect chest X-ray.
261
chronic constipation. However, in the review by Serpell and Nicholls,8 only 61% of patients gave a history of constipation, which undoubtedly reflects the challenge of ‘‘diagnosing’’ constipation (and specifically opioid-induced constipation).5 Drug-induced constipation is a recognized cause of stercoral perforation of the colon, but opioid-induced constipation appears to be a relatively uncommon cause. Indeed, in the review by Serpell and Nicholls,8 only 8% of patients were taking opioids, whereas 16% of patients were taking antacids containing aluminum hydroxide (which also induce constipation). Stercoral perforation of the colon occurs in stepwise manner:9,13 ongoing constipation results in the formation of a fecoloma (localized hard fecal mass) that exerts pressure on the intestinal wall; this may compromise the vascular supply to the bowel wall, which may lead to ulceration of the bowel wall (‘‘stercoral ulcer’’), which may lead to perforation of the bowel wall. Stercoral perforations occur predominantly in the sigmoid colon/rectosigmoid junction;8 this relates to the fact that the stool gets more dehydrated as it passes through the large bowel and that these areas have a somewhat narrow diameter (compared with the rest of the large bowel). Equally, stercoral perforations occur predominantly on the anti-mesenteric border of the colon, and this relates to the fact that these areas have a somewhat meager blood supply. Maurer et al.9 have proposed the following diagnostic criteria for stercoral perforation of the colon: 1) the colonic perforation is round or ovoid, exceeds 1 cm in diameter, and lies antimesenterial; 2) fecalomas are present within the colon, protruding through the perforation site or lying within the abdominal cavity; and 3) pressure necrosis or ulcer and chronic inflammatory reaction around the perforation site are present microscopically. In addition, the perforation has to be in an ‘‘otherwise normal’’/non-diseased colon.9 Thus, the diagnosis depends not only on the clinical findings but also on the pathological findings. Constipation may contribute to other forms of colonic perforation (i.e., in patients with an abnormal/ diseased colon), and certain constipation interventions also have been associated with traumatic colonic perforation.14 Stercoral ulceration (precursor to stercoral perforation) is invariably asymptomatic, although some patients may present with gastrointestinal hemorrhage.13,15 In contrast, stercoral perforation is invariably highly symptomatic, with 20% of patients having clinical features of localized peritonitis, and 80% of patients having clinical features of generalized peritonitis.8 Plain abdominal/ chest X-rays show gross fecal loading in almost all instances and intra-abdominal air in 70% of instances (e.g., subdiaphragmatic).9 Similarly, computed
262
Davies and Webber
tomography scans of the abdomen show ‘‘diagnostic features’’ in 90% of instances (e.g., fecal impaction, intraabdominal feces, intra-abdominal air, pericolic stranding).16,17 The mortality is high and is influenced by the management of the perforation (47% of whole group; 35% of group undergoing surgery).8 Indeed, conservative/non-surgical management is invariably unsuccessful in this situation (in contrast, e.g., to diverticulitis-related colonic perforation). The surgical management of stercoral perforation of the colon involves resuscitation, intravenous antibiotics, early surgery (with resection of the diseased colon, exteriorization of the remaining colon, and peritoneal lavage), and other appropriate supportive measures.8,18 It is important that residual fecalomas are removed from the remaining colon (to prevent further stercoral ulcers/perforations) and that consideration is given to removing other areas of diseased/ distended colon (which may be the site of further stercoral ulcers).9
Conclusion Stercoral perforation of the colon is a rare complication of opioid-induced constipation. Adequate management of constipation, and particularly of patients with fecal impaction and/or presence of fecalomas, should help to further reduce the risk of this lifethreatening condition.
Disclosures and Acknowledgments No funding was received for this work and the authors declare no conflicts of interest.
References 1. World Health Organization. Cancer pain relief, 2nd ed. Geneva, Switzerland: World Health Organization, 1996. 2. Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician 2008;11(Suppl 2): S105eS120. 3. Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based
Vol. 50 No. 2 August 2015
recommendations from the EAPC. Lancet Oncol 2012;13: e58ee68. 4. De Schepper HU, Cremonini F, Park MI, Camilleri M. Opioids and the gut: pharmacology and current clinical experience. Neurogastroenterol Motil 2004;16:1e12. 5. Camilleri M, Drossman DA, Becker G, Webster LR, Davies AN, Mawe GM. Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid-induced constipation. Neurogastroenterol Motil 2014;26:1386e1395. 6. Larkin PJ, Sykes NP, Centeno C, et al. The management of constipation in palliative care: clinical practice recommendations. Palliat Med 2008;22:796e807. 7. Sykes N. Constipation and diarrhoea. In: Hanks G, Cherny NI, Christakis NA, Fallon M, Kaasa S, Portenoy RK, eds. Oxford textbook of palliative medicine, 4th ed. Oxford, England: Oxford University Press, 2010:833e850. 8. Serpell JW, Nicholls RJ. Stercoral perforation of the colon. Br J Surg 1990;77:1325e1329. 9. Maurer CA, Renzulli P, Mazzucchelli L, Egger B, Seiler CA, B€ uchler MW. Use of diagnostic criteria may increase incidence of stercoral perforation of the colon. Dis Colon Rectum 2000;43:991e998. 10. Russell WL. Stercoraceous ulcer. Am Surg 1976;42: 416e420. 11. Kwag SJ, Choi SK, Park JH, et al. A stercoral perforation of the rectum. Ann Coloproctol 2013;29:77e79. 12. Berry J. Dilation and rupture of sigmoid flexure. Br Med J 1894;1:301. 13. Grinvalsky HT, Bowerman CI. Stercoraceous ulcers of the colon: relatively neglected medical and surgical problem. JAMA 1959;171:1941e1946. 14. Paran H, Butnaru G, Neufeld D, Magen A, Freund U. Enema-induced perforation of the rectum in chronically constipated patients. Dis Colon Rectum 1999;42:1609e1612. 15. Huang CC, Wang IF, Chiu HH. Lower gastrointestinal bleeding caused by stercoral ulcer. CMAJ 2011;1883:E134. 16. Kumar P, Pearce O, Higginson A. Imaging manifestations of faecal impaction and stercoral perforation. Clin Radiol 2011;66:83e88. 17. Chakravartty S, Chang A, Nunoo-Mensah J. A systematic review of stercoral perforation. Colorectal Dis 2013;15: 930e935. 18. Guyton DP, Evans D, Schreiber H. Stercoral perforation of the colon. Concepts of operative management. Am Surg 1985;51:520e522.
Journal of Pain and Symptom Management
Vol. 50 No. 2 August 2015
Clinical Note
Stercoral Perforation of the Colon: A Potentially Fatal Complication of Opioid-Induced Constipation Andrew Davies, FRCP, and Katherine Webber, PhD Royal Surrey County Hospital, Guildford, Surrey, United Kingdom
Abstract Stercoral perforation of the colon is a rare complication of constipation, and there have only been a few reported cases of stercoral perforation of the colon secondary to opioid-induced constipation. This article describes such a case in a cancer survivor with chronic cancer-related pain and reviews the medical/surgical literature on stercoral perforation of the colon. J Pain Symptom Manage 2015;50:260e262. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Stercoral perforation, opioid analgesics, opioid-induced constipation
Introduction Opioid analgesics are the cornerstone of the management of cancer pain,1 and constipation is a wellrecognized common side effect of this group of drugs.2 Indeed, learned guidelines recommend that patients are co-prescribed appropriate laxatives with opioid analgesics.1,3 Opioids have a number of actions on the gastrointestinal tract;4 opioid-induced constipation is related to a decrease in gastrointestinal motility (small bowel, large bowel), a decrease in small bowel fluid secretion, an increase in large bowel fluid reabsorption, an increase in sphincter tone (ileocecal valve, anal sphincter), and a decrease in anorectal sensitivity.5 Opioid-induced constipation is associated with a variety of physical, psychological, and social consequences.6 Physical symptoms include anorexia, nausea, vomiting, abdominal bloating, and abdominal discomfort/pain; physical complications include fecal impaction, intestinal obstruction, fecal incontinence, hemorrhoids, urinary incontinence, and urinary retention.6,7 Stercoral perforation of the colon is a rare complication of constipation, and there have only been a few reported cases of stercoral perforation of the colon secondary to opioid-induced constipation.8,9 This article describes such a case in a cancer
Address correspondence to: Andrew Davies, FRCP, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU2 7XX, UK. E-mail: [email protected] Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
survivor with chronic cancer-related pain and reviews the medical/surgical literature on stercoral perforation of the colon.
Case Report The patient was a 67-year-old woman, who had been diagnosed with Stage IV B, diffuse large B-cell lymphoma, and who had achieved a complete response with R-CHOP (rituximab, cyclophosphamide, hydroxydaunomycin, OncovinÒ, prednisone) chemotherapy. She was referred for management of chronic back pain, which was secondary to vertebral collapse (secondary to previous lymphoma). The back pain was controlled with modified-release oxycodone, and she was prescribed laxatives to treat/prevent constipation. Initially she was given a high dose of a macrogol laxative to treat fecal impaction from her previous opioid analgesic. Subsequently, she was given standard doses of senna and sodium docusate to prevent constipation. She reported no further problems with constipation and was assumed to be taking regular laxatives (The patient was repeatedly advised about taking regular laxatives to prevent constipation). A few months after referral, she presented as an emergency with acute abdominal pain. On
Accepted for publication: February 15, 2015.
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2015.02.019
Vol. 50 No. 2 August 2015
Opioid-Induced Stercoral Perforation of the Colon
examination, she had signs of septic shock and generalized peritonitis. A chest X-ray demonstrated free air under the diaphragm (Fig. 1). She was medically stabilized and then underwent an emergency laparotomy. At operation, she was found to have a perforation of the transverse colon, with fecal matter in the peritoneal cavity and colon; the transverse colon was resected, and the peritoneal cavity was thoroughly ‘‘washed out.’’ She was transferred to the intensive care unit for ongoing management of the sepsis and related problems. However, she died from complications of the sepsis five days later. Histology of the resected transverse colon was consistent with a stercoral perforation; there was no evidence of recurrent lymphoma.
Discussion Stercoral perforation has been defined as ‘‘perforation of the bowel due to pressure necrosis from fecal masses.’’8 It is a somewhat ‘‘rare’’ phenomenon, with stercoral perforation of the terminal ileum, cecum and rectum being an even less common phenomenon.8,10,11 Thus, Serpell and Nicholls8 reviewed the literature from 1894 (date of the first recorded case12) to 1990 and identified a total of 64 cases. Similarly, Maurer et al.9 reviewed the literature from 1894 to 1998 and identified a total of 81 cases, although they also reported a further seven cases managed in their unit in the preceding five-year period. It should be noted that the seven cases reported by Maurer et al. represented only 3.2% of patients with perforation of the colon managed in their unit during this time period. Unsurprisingly, the major predisposing factor to stercoral perforation of the colon is the presence of
Fig. 1. Patient’s erect chest X-ray.
261
chronic constipation. However, in the review by Serpell and Nicholls,8 only 61% of patients gave a history of constipation, which undoubtedly reflects the challenge of ‘‘diagnosing’’ constipation (and specifically opioid-induced constipation).5 Drug-induced constipation is a recognized cause of stercoral perforation of the colon, but opioid-induced constipation appears to be a relatively uncommon cause. Indeed, in the review by Serpell and Nicholls,8 only 8% of patients were taking opioids, whereas 16% of patients were taking antacids containing aluminum hydroxide (which also induce constipation). Stercoral perforation of the colon occurs in stepwise manner:9,13 ongoing constipation results in the formation of a fecoloma (localized hard fecal mass) that exerts pressure on the intestinal wall; this may compromise the vascular supply to the bowel wall, which may lead to ulceration of the bowel wall (‘‘stercoral ulcer’’), which may lead to perforation of the bowel wall. Stercoral perforations occur predominantly in the sigmoid colon/rectosigmoid junction;8 this relates to the fact that the stool gets more dehydrated as it passes through the large bowel and that these areas have a somewhat narrow diameter (compared with the rest of the large bowel). Equally, stercoral perforations occur predominantly on the anti-mesenteric border of the colon, and this relates to the fact that these areas have a somewhat meager blood supply. Maurer et al.9 have proposed the following diagnostic criteria for stercoral perforation of the colon: 1) the colonic perforation is round or ovoid, exceeds 1 cm in diameter, and lies antimesenterial; 2) fecalomas are present within the colon, protruding through the perforation site or lying within the abdominal cavity; and 3) pressure necrosis or ulcer and chronic inflammatory reaction around the perforation site are present microscopically. In addition, the perforation has to be in an ‘‘otherwise normal’’/non-diseased colon.9 Thus, the diagnosis depends not only on the clinical findings but also on the pathological findings. Constipation may contribute to other forms of colonic perforation (i.e., in patients with an abnormal/ diseased colon), and certain constipation interventions also have been associated with traumatic colonic perforation.14 Stercoral ulceration (precursor to stercoral perforation) is invariably asymptomatic, although some patients may present with gastrointestinal hemorrhage.13,15 In contrast, stercoral perforation is invariably highly symptomatic, with 20% of patients having clinical features of localized peritonitis, and 80% of patients having clinical features of generalized peritonitis.8 Plain abdominal/ chest X-rays show gross fecal loading in almost all instances and intra-abdominal air in 70% of instances (e.g., subdiaphragmatic).9 Similarly, computed
262
Davies and Webber
tomography scans of the abdomen show ‘‘diagnostic features’’ in 90% of instances (e.g., fecal impaction, intraabdominal feces, intra-abdominal air, pericolic stranding).16,17 The mortality is high and is influenced by the management of the perforation (47% of whole group; 35% of group undergoing surgery).8 Indeed, conservative/non-surgical management is invariably unsuccessful in this situation (in contrast, e.g., to diverticulitis-related colonic perforation). The surgical management of stercoral perforation of the colon involves resuscitation, intravenous antibiotics, early surgery (with resection of the diseased colon, exteriorization of the remaining colon, and peritoneal lavage), and other appropriate supportive measures.8,18 It is important that residual fecalomas are removed from the remaining colon (to prevent further stercoral ulcers/perforations) and that consideration is given to removing other areas of diseased/ distended colon (which may be the site of further stercoral ulcers).9
Conclusion Stercoral perforation of the colon is a rare complication of opioid-induced constipation. Adequate management of constipation, and particularly of patients with fecal impaction and/or presence of fecalomas, should help to further reduce the risk of this lifethreatening condition.
Disclosures and Acknowledgments No funding was received for this work and the authors declare no conflicts of interest.
References 1. World Health Organization. Cancer pain relief, 2nd ed. Geneva, Switzerland: World Health Organization, 1996. 2. Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician 2008;11(Suppl 2): S105eS120. 3. Caraceni A, Hanks G, Kaasa S, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based
Vol. 50 No. 2 August 2015
recommendations from the EAPC. Lancet Oncol 2012;13: e58ee68. 4. De Schepper HU, Cremonini F, Park MI, Camilleri M. Opioids and the gut: pharmacology and current clinical experience. Neurogastroenterol Motil 2004;16:1e12. 5. Camilleri M, Drossman DA, Becker G, Webster LR, Davies AN, Mawe GM. Emerging treatments in neurogastroenterology: a multidisciplinary working group consensus statement on opioid-induced constipation. Neurogastroenterol Motil 2014;26:1386e1395. 6. Larkin PJ, Sykes NP, Centeno C, et al. The management of constipation in palliative care: clinical practice recommendations. Palliat Med 2008;22:796e807. 7. Sykes N. Constipation and diarrhoea. In: Hanks G, Cherny NI, Christakis NA, Fallon M, Kaasa S, Portenoy RK, eds. Oxford textbook of palliative medicine, 4th ed. Oxford, England: Oxford University Press, 2010:833e850. 8. Serpell JW, Nicholls RJ. Stercoral perforation of the colon. Br J Surg 1990;77:1325e1329. 9. Maurer CA, Renzulli P, Mazzucchelli L, Egger B, Seiler CA, B€ uchler MW. Use of diagnostic criteria may increase incidence of stercoral perforation of the colon. Dis Colon Rectum 2000;43:991e998. 10. Russell WL. Stercoraceous ulcer. Am Surg 1976;42: 416e420. 11. Kwag SJ, Choi SK, Park JH, et al. A stercoral perforation of the rectum. Ann Coloproctol 2013;29:77e79. 12. Berry J. Dilation and rupture of sigmoid flexure. Br Med J 1894;1:301. 13. Grinvalsky HT, Bowerman CI. Stercoraceous ulcers of the colon: relatively neglected medical and surgical problem. JAMA 1959;171:1941e1946. 14. Paran H, Butnaru G, Neufeld D, Magen A, Freund U. Enema-induced perforation of the rectum in chronically constipated patients. Dis Colon Rectum 1999;42:1609e1612. 15. Huang CC, Wang IF, Chiu HH. Lower gastrointestinal bleeding caused by stercoral ulcer. CMAJ 2011;1883:E134. 16. Kumar P, Pearce O, Higginson A. Imaging manifestations of faecal impaction and stercoral perforation. Clin Radiol 2011;66:83e88. 17. Chakravartty S, Chang A, Nunoo-Mensah J. A systematic review of stercoral perforation. Colorectal Dis 2013;15: 930e935. 18. Guyton DP, Evans D, Schreiber H. Stercoral perforation of the colon. Concepts of operative management. Am Surg 1985;51:520e522.
