A Clinical Case Study and Review of the Literature on Stercoral Ulcer Perforation: An Uncommon but Deadly Culprit

Abstract

A B S T R A C T Stercoral ulcer perforation (SUP) was first described in 1894. Fewer than 150 cases have been reported in the literature. Historically, stercoral ulcers (SU) are mostly seen in older patients. However, in recent years younger patients have presented with this condition. Stercoral ulcers are caused by impacted feces, which result in loss of bowel wall integrity due to chronic pressure necrosis. This can lead to perforation and fecal peritonitis. It is a deadly but rare complication of chronic constipation. The case of a 78-year-old woman with a history of chronic constipation who presented to the emergency department (ED) with diffuse abdominal pain is described. Initial imaging studies revealed severe fecal impaction, most significant in the sigmoid and rectum. The patient was admitted for observation with serial abdominal exams, however, during the hospital course her clinical status deteriorated over a 12-hour period. Abdominal x-ray demonstrated free air under the diaphragm, and the patient was taken to the operating room (OR) for emergency exploratory laparotomy. Colorectal perforation was discovered and repaired. The patient tolerated the surgical intervention, but unfortunately died during the post-operative period. The patient's history of chronic constipation, immobility, and opioid use for pain management after knee surgery most likely precipitated the stercoral ulceration and colonic perforation.In this study, a systematic review was conducted to assess the epidemiology, presentation, diagnosis, management, complications, and clinical implications associated with stercoral ulcers.

Rare Presentation of Stercoral Ulcer Spontaneous Perforation Without Preceding Radiographic Evidence of Colonic Inflammation and Fecal Impaction

“…The single greatest risk factor is chronic constipation, present in 81% of all patients [ 5 ]. The most commonly associated drugs which precipitate constipation are: opioids, tricyclic antidepressants, and anticholinergics [ 1 ]. In this case report, we report a patient, in whom we saw the chronic opioid dependence was a major risk factor that predisposed her to chronic constipation.…”

“…Patients present with benign symptoms with non-perforated stercoral ulcers: abdominal pain, vomiting, rectal discomfort, constipation, etc. Patients with perforation have bloody stools with signs of peritoneal inflammation [ 1 ]. Our patient presented with signs of peritoneal inflammation but no bloody diarrhea.…”

“…CT abdomen has an important role in identifying this life-threatening complication of stercoral ulcers. Some of the findings are: colonic dilatation >6 cm, colonic wall thickening >3 mm, pericolonic fat stranding, mucosal discontinuity, presence of free air, free fluid, and pericolonic abscess [ 1 , 5 ]. Initial CT abdomen for our patient did not show any signs of bowel inflammation, abscess, or fecal impaction to suggest stercoral ulcer, which usually precedes before perforation.…”

“…The diagnosis is made during exploratory laparotomy and fecalomas coming through the perforated ulcer is diagnostic [ 1 ]. Similarly, our patient was diagnosed with SUP during the exploratory laparotomy.…”

“…Stercoral colitis is a rare inflammatory process most commonly of the rectosigmoid colon related to prolonged fecal impaction associated with chronic constipation and colonic dysfunction [ 1 ]. Ischemic necrosis and stercoral ulcer formation can result, with the potential for subsequent colonic perforation [ 2 ].…”