Stercoral perforation of the normal colon : Report of five cases

A series of five consecutive patients with stercoral perforation of the colon is presented. Four of the patients had free perforation and one had an abscess between the splenic flexure, spleen and surrounding organs, a yet unreported entity. All patients underwent emergency surgery including laparostomy with repeated explorations and lavages in two of them. The ethiology, pathophysiology and treatment of the condition are updated. A graphic algorithm for decision-making in appropriately dealing with stercoral perforation of the colon is proposed.


PATIENTS AND METHODS
Five patients with stercoral perforation of the normal colon were treated at the Department of Emergency Surgery of the Military Medical Academy of Sofia, Blilgaria, between 1975 and 1995.A summary of the principal findings in these patients is presented in Table I.
Virtually all patients presented an acute, nonspectic abdomen condition.Past medical history revealed the following (Table 2).In all patients there was marked leucocytosis shifted to the left, marked fluid imbalance and arterial hypotony.An abdominal x-ray showed free air below the diaphragm in all but Case 2, in which emergency abdominal ultrasonography revealed a large abscess between the left colonic flexure and the spleen (Fig. I).All patients underwent emergency laparotomies through xyphopubic incisions, with the suspicion of a hollow organ perforation.

RESULTS
In all five patients, the resected colonic segments were examined by a pathologist, both macroscopically and histologically.Maroscopically, the perforations had necrotic, inflammed edges; from inside the bowel, there was extensi ve necrosis of mucosa considerably larger than the site of the actual perforation.Microscopically, necrosis of perforation's edges was found (Fig. 2), with phlegmonous inflammation of the bowel wall of different degrees depending on the di'sta'nce from the perforation (Fig. 3).
All patients who survived recieved life-long medications with mild aperients.None of them presented obstipation or complaints attributable to the presence of fecalomas in the colon.
The operative findings are listed in Table 3.In all patients, large fecalomas were found plugging the defects of the colonic walls, in all of them the colon was found to be filled with multiple fecalomas of different size from the ileocecal valve up to the rectal ampula.No associated intra-abdominal pathology was found, including all possible lesions that might contribute for a difficult gastrointestinal passage (adhesions, strictures, etc.) The operations performed and the final outcome are presented in Table 4.

DISCUSSION
There is a general agreement in the current literature regarding the definition of stercoral perforation of the normal colon, namely "perforation of the bowel due to pressure necrosis from hard fecal masses".1.2The morphologic changes of the bowel wall are typical: the perforation's edges are necrotic and intlammed; often a large fecaloma pluggs the defect (Fig. 4),corresponding in size to the perforation, and both macroscopically and microscopically there is ulceration of the mucosa with acute and chronic inflammation. 3All the patients from this series fulfilled the above-mentioned criteria so as to be undoubtedly included in this category.
To the best of our knowledge, only 67 cases of stercoral perforation of the normal colon have been described to date in the English language literature.1.4.5 Patient's age range between 16 and 83 years (average, 59.3) with both sexes being almost equally affected.Typically, patients are elderly and inactive; as a rule, there is a long history of constipation or use of constipating agents such as anticholinergics, ganglionic blockers, tricyclic antidepresants, phenothiazine neuroleptics and steroids, but this does not seem universally valid for every case reported.v ) Longtanding obstipation has been ascribed to barium enema?as well.Recently, stercoral perforation of the colon has been ascribed to intensive activated charcoal treatment.5 In this series, only one of the patients had no history of obstipation-causing long-term medication, but

Table 2
Past medical history of the patient from the series.indeed, this patient had suffered from longstanding obstipation which might be the logical cause of his disease (Case 1).There was a history of such medication among the other patients (Table 2), as well as that of longstandi ng obstipation as the possible result of this medication.
Thus, we consider neglected constipation to be at least one of the major causes of stercoral perforation of the colon, as outlined by most of the other authors.I-3.5.C,.x-" The avoidance of constipation, particularly among patients treated by constipative drugs, may eliminate, at least theoretical1y, the risks of stercoral perforation of the colon.Other factors thought to be implicated are hernias, haustrae, foreign bodies, or intestinal strictures.lOIn fact, such pathology was not present among our patients, thus, we consider it to be of secondary importance.
As exceptions, stercoral perforations can be found among young patients with spinal cord injury, or among patients  At operation, most perforations are found to be single (79 %) and located on the anti mesenteric aspect of the sigmoid and rectosigmoid (17 % and 30 %, respectively), followed by the cecum (9 %), transverse colon (7 %), descending colon (5 %), and splenic flexure (2 %).11 Qur Case 2 seems extremely interesting in respect to the lack of free perforation of the colon but of the presence of a well-established abscess filled with pus and fecalomas, to our knowledge, a yet unreported condition.
Findings 1.5/1 em.perforation of the cecum; phlegmona of the bowel wall up to the midascending colon; generalized purulent peritonitis 2/1 em.perforation of the midsigmoid; 1/1.5 em.perforation of the upper rectum; bowel phlegmona up.to the midtransverse colon; generalized feculent peritonitis 2/2.5 em.perforation of the splenic flexure; abscess between the lasser, stomach, spleen, and abdominal wall filled with multiple fecalomas; serous peritonitis   In our opinion, an abscess intimately adherent to the colon in a patient with longstanding constipation should also arize suspicion for a walled-of stercoral perforation.
The inflammatory process as a rule involves a whole segment of the colon 2 ; the latter is often loaded with hard scibala.X.lJ Furthermore, the necrotic changes on the inner surface of the bowel extended wide from perforation's edges.1.3Among the cases described, all presented phlegmonous inflammation of a whole colonic segment, the colon of each was found to be loaded with multiple fecalomas, and the necrotic changes on the inner surface of the bowel extended considerably from the actual perforation's edges.All this should be always taken into consideration in order to prevent inadequate surgical treatment consisting of simple closure of the lesion or of a limited resection, without cleaning the residual colon from all the redundant fecal material.
The most frequently performed procedure having the highest survival rate is reported to be resection with colostomy.3.6.xHowever, in order to escape the risk of a further perforation during the postoperati ve period, caused by retained fecalomas, intraoperative orthograde colonic lavage must be included as an essential part of the complex surgical treatment. 4In two of our cases, milking of the colon was performed instead of lavage as there were no facilities for the latter.Nevertheless, the colon of all our patients was cleaned intraoperatively and no perforations occurred during the postoperative period nor were perforations discovered at autopsy in the two patients who died.This was due to their both their advanced age and degree of intoxication but, it is our opinion that, in advanced cases, laparostomy with repeat lavages and debridement may probably aid in achieving a higher survival figure.
Mortality is still unacceptably high in this condition, approaching 35%.1-3Possible.reasonsfor the poor 1323 prognosis include an older patient age group, rapid clinical deterioration immediately following perforation, and well-established fecal peritonitis at the time of surgery.II The results can be improved only by rapid surgical intervention and aggressive resuscitation.Otherwise, longstanding obstipation should never be neglected but instead, actively treated.Interestingly, no uniform guidelines for surgical treatment have been outlined to date in the literature.Based on our experience with this series of five patients, and on the data from the Iiterature, the fo 1I0wi ng graph ic algori th m can be proposed to contribute to more appropriately dealing with stercoral perforation of the colon from the surgical poi nt of view (Table 5).

Figure 1 -
Figure 1 -Abdominal ultrasonography reveals,a large abscess between the left colonic flexure and the spleen.

Figure 2 -
Figure 2 -Histology from the edges of a stercoral perforation displaying extensive necrosis and acute inflammatory changes.Hematoxylin & eosin, x 44.

Figure 3 -
Figure 3 -Histology from the same specimen taken in the close proximity of the actual perforation's site and displaying transmural phlegmonous inflammation of the bowel wall.Hematoxylin & eosin, x 44.
obstipation /8 years/ due to 8 years ganglionic blockers therapy for hypertension 15 years of obstipation; 9 years of tricyclic anti depresants treatment for depression 11 years of obstipation; 6 years of anticholinergics for allergic state 19 years of uninvestigated obstipation; 8 years of chroniodialysis for renal insufficiency; 4 years of phenothiazine neuroleptics previous operations appendectomy 22 years previously hysterectomy 21 years previously bilateral nephrolithotomy, respective Iy 10 and 3 years previously 4/3 em.perforation of the cecum; local bowel phlegmona surrounding the perforation; generalized feculent peritonitis

Figure 4 -
Figure 4 -Artist's drawing illustrating stercoral perforation the sigmoid colon with a large conglomerate of fecalomas plugging the defect.The entire colon is filled with multiple fecalomas, from the ileocecal valve up to the rectum.

Table 1
Summary of principal findings in five patients with stercoral perforation of the normal colon.

Table 3 Operative findings for five patients with stercoral perforation of the colon.
of manifested, prolonged fecal impaction, which is typical for most of the cases from the literature.I -J 1.5/1.5 em.perforation of the midsigmoid; bowel phlegmona up to the midtransverse colon; left lower quadrant purulent peritonitis there a history