Pathophysiological analysis and strategy for stercoral perforation of the colon

Koichi Sato, Hiroshi Maekawa, Mutsumi Sakurada, Hajime Orita, Tomoaki Ito, Yoshihiro Komatsu, Fumiko Hirata, Ryo Wada

Department of Pathology, Juntendo Shizuoka Hospital, Juntendo University School of Medicine.
Department of Surgery, Juntendo Shizuoka Hospital, Juntendo University School of Medicine.

DOI: 10.4236/ojgas.2012.22010                

Abstract

Perpose: In order to establish the pathophysiological features and strategy for stercoral perforation of the colon, we herein analyze a series of stercoral perforation of the colon. Method: Ten patients were diagnosed with stercoral perforation. Clinical features, primary diseases, triggers, causative bacteria in ascites, postoperative complications, pathological features, severity of the disease, and effect of direct hemoperfusion with polymyxin B immobilized fiber (PMX-DHP) were investigated. Results: Nine patients had a long history of serious and chronic constipation and 7 patients had hypertension. Causative bacteria in ascites during the operation were most commonly Escherichia coli. There were a lot of severe postoperative complications such as sepsis, disseminated intravascular coagulation, and acute lung injury. With regard to the microscopic findings of the perforation site, the intestinal wall showed severe nonspecific inflammatory changes, including an increase of mono-nuclear cells in the lamina propria. There were 4 hospital deaths, so the mortality rate was 40%. APACHE- II and SOFA score were high postoperation and 24 hours after the operation. PMX-DHP was performed in 8 cases of severe conditions of stercoral perforation of the colon. Because the catecholamine index improved within 24 hours, four of 8 cases were rescued. Conclusion: Most of the patients with stercoral perforation of the colon had severe postoperative complications. The severity of the disease was extremely high, therefore, early diagnosis based on pathophy-siological features and comprehensive therapies including PMX-DHP were necessary for strategy of treating stercoral perforation of the colon.

Keywords

Stercoral Perforation of the Colon; APACHE-II Score; SOFA Score; Polymyxin B Immobilized Fiber (PMX-DHP)

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Bauer, J.J., Weiss, M. and Dreiling, D.A. (1972) Ster-coraceous perforation of the colon. Surgical Clinics of North America, 52, 1047-1053.
[2]	Dubinsky, I. (1996) Stercoral perforation of the colon: case report and review of the literature. Jourmal of Emergency Medicine, 14, 323-325. doi:10.1016/0736-4679(96)00044-3
[3]	Gul, Y.A., Waldron, D.J. and O’Connell, P.R. (1997) Stercoral perforation associated with parathyroid adenoma. Irish Medical Journal, 90, 20.
[4]	DeJong, J.L., Cohle, S.D. and Busse, F. (1996) Fetal stercoral ulcer perforation: case report. American Journal of Forensic Medecine and Pathology, 17, 58-60. doi:10.1097/00000433-199603000-00010
[5]	Serpell, J.W. and Nicholls, R.J. (1990) Stecoral perfora- tion of the colon. British Journal of Surgery, 77, 1325- 1329. doi:10.1002/bjs.1800771204
[6]	Strutynsky, N. and Orron, D. (1987) Stercoral perforation of the descending colon appearing radiographically as pneumomediastinum. Mount Sinai Journal of Medicine, 54, 436-439.
[7]	Gekas, P. and Schuster, M. (1981) Stercoral perforation of the colon: case report and review of the literature. Gastroenterology, 80, 105.
[8]	Maurer, C.A., Renzulli, P., Mazzucchelli, L., et al. (2000) Use of accurate diagnostic criteria may increase incidence of stercoral perforation of the colon. Diseases of Colon and Rectum, 43, 991-998. doi:10.1007/BF02237366
[9]	Knaus, W.A., Draper, E.A., Wagner, D.P., et al. (1985) APACHE-II score: A severity of disease classification system. Critical Care Medicine, 13, 818-829. doi:10.1097/00003246-198510000-00009
[10]	Vincent, J.L., Moreno, R., Takara, J., et al. (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Medicine, 22, 707-710. doi:10.1007/BF01709751
[11]	Berry, J. (1894) Dilatation and rupture of sigmoid flexure [short report]. British Medical Journal, 1, 301.
[12]	Carter, D.C. and Kirkpatrick, J.R. (1973) Stercoral perforation of the sigmoid colon. British Journal of Surgery, 60, 61-63. doi:10.1002/bjs.1800600117
[13]	Sharma, M. and Agrawal, A. (2010) Case report: Stercoral sigmoid colonic perforation with fecal peritonitis. Indian Journal of Radiology and Imaging, 20, 126-128. doi:10.4103/0971-3026.63051
[14]	Wald, A. (2008) Management and prevention of fecal impaction. Current Gastroenterology Reports, 10, 499- 501. doi:10.1007/s11894-008-0091-y
[15]	Nam, J.K., Kim, B.S., Kim, K.S., et al. (2010) Clinical analysis of stercoral perforation of the colon. Korean Journal of Gastroenterology, 55, 46-51. doi:10.4166/kjg.2010.55.1.46
[16]	Grinvalsky, H.T. and Bowenman, C.I. (1959) Sterco-raceous ulcers of the colon; relatively neglected medical and surgical problem. The Journal of the American Medical Association, 171, 1941-1946. doi:10.1001/jama.1959.03010320031008
[17]	Lyon, D.C. and Sheiner, H.J. (1969) Idiopathic rectosigmoid perforation. Surgery Gynecology and Obstetrics, 128, 991-1000
[18]	Barardi, R.S., Lee, S.S., Chen, H.P., et al. (1987) Stercoraceous and spontaneous perforation of the colon. International Surgery, 72, 235-240.
[19]	Guyton, D.P., Evans, D. and Schreiber, H. (1985) Ster-coral perforation of the colon. Concepts of operative management. American Journal of Surgery, 51, 520-522.
[20]	Sung, J.F., Salvay, H.B., Hansman, M.F., et al. (2009) Stercoral perforation of the colon with favorable pregnancy outcome. Obstetrics and Gynecology, 113, 491- 492.
[21]	Vincent, J.L., Laterre, P.F., Cohen, J., et al. (2005) A pilot-controlled study of a polymyxin B-immobilized hemoperfusion cartridge in patients with severe sepsis secondary to intra-abdominal infection. Shock, 23, 400- 405. doi:10.1097/01.shk.0000159930.87737.8a
[22]	Cruz, D.N., Perazella, M.A., Bellomo, R., et al. (2007) Effectiveness of polymyxin B-immobilized fiber column in sepsis; a systematic review. Critical Care, 11, 47. doi:10.1186/cc5780
[23]	Cruz, D.N., Antonelli, M., Fumagalli, R., et al. (2009) Early use of polymyxin B hemoperfusion in abdominal septic shock. The Journal of the American Medical Association, 301, 2445-2452. doi:10.1001/jama.2009.856