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Perforation in a Patient with Stercoral Colitis and Diverticulosis: Who Did It? V Donald and Barbara Zucker School of Medicine Journal Articles Academic Works 2014 Perforation in a patient with stercoral colitis and diverticulosis: who did it? V. R. Bhatt Northwell Health S. Murukutla Northwell Health J. Dipoce Northwell Health S. Gustafson Northwell Health D. Sarkany Northwell Health See next page for additional authors Follow this and additional works at: https://academicworks.medicine.hofstra.edu/articles Part of the Gastroenterology Commons, and the Internal Medicine Commons Recommended Citation Bhatt ,V Murukutla S, Dipoce J, Gustafson S, Sarkany D, Mody K, Widmann W, Gottesman A. Perforation in a patient with stercoral colitis and diverticulosis: who did it?. 2014 Jan 01; 4():Article 2418 [ p.]. Available from: https://academicworks.medicine.hofstra.edu/articles/2418. Free full text article. This Article is brought to you for free and open access by Donald and Barbara Zucker School of Medicine Academic Works. It has been accepted for inclusion in Journal Articles by an authorized administrator of Donald and Barbara Zucker School of Medicine Academic Works. For more information, please contact [email protected]. Authors V. R. Bhatt, S. Murukutla, J. Dipoce, S. Gustafson, D. Sarkany, K. Mody, W. D. Widmann, and A. Gottesman This article is available at Donald and Barbara Zucker School of Medicine Academic Works: https://academicworks.medicine.hofstra.edu/articles/2418 JOURNAL OF COMMUNITY HOSPITAL INTERNAL MEDICINE PERSPECTIVES æ CASE REPORT Perforation in a patient with stercoral colitis and diverticulosis: who did it? Vijaya R. Bhatt, MBBS1*, Srujitha Murukutla, MBBS1, Jason DiPoce, MD2, Steven Gustafson, DO3, David Sarkany, MD2, Kokila Mody, MD3, Warren D. Widmann, MD4,5 and Aaron Gottesman, MD, FACP, SFHM1 1Department of Medicine, Staten Island University Hospital, Staten Island, New York, USA; 2Department of Radiology, Staten Island University Hospital, Staten Island, New York, USA; 3Department of Pathology and Laboratory Medicine, Staten Island University Hospital, Staten Island, New York, USA; 4Department of Surgery, Staten Island University Hospital, Staten Island, New York, USA; 5Department of Surgery, Downstate Medical Center, State University of New York, Brooklyn, New York, USA Stercoral colitis with perforation of the colon is an uncommon, yet life-threatening cause of the acute abdomen. No one defining symptom exists for stercoral colitis; it may present asymptomatically or with vague symptoms. Diagnostic delay may result in perforation of the colon resulting in complications, even death. Moreover, ster- coral perforation of the colon can also present with localized left lower quadrant abdominal pain masquerading as diverticulitis. Diverticular diseases and stercoral colitis share similar pathophysiology; furthermore, they may coexist, further complicating the diagnostic dilemma. The ability to decide the cause of perforation in a patient with both stercoral colitis and diverticulosis has not been discussed. We, therefore, report this case of stercoral perforation in a patient with diverticulosis and include a discussion of the epidemiology, clinical presentation, and a review of helpful diagnostic clues for a rapid differentiation to allow for accurate diagnosis and treatment. Keywords: stercoral colitis; stercoral perforation; diverticular disease; acute abdomen *Correspondence to: Vijaya R. Bhatt, Staten Island University Hospital, Department of Internal Medicine 475 Seaview Avenue, Staten Island, New York 10305, USA, Email: [email protected] Received: 24 September 2013; Accepted: 1 January 2014; Published: 17 February 2014 tercoral perforation of the colon is an uncommon and vomiting of 4 days duration. Medical history was life-threatening cause of the acute abdomen and significant for chronic constipation, osteoarthritis, and Smust be recognized promptly to ensure proper seasonal allergies. She had a remote history of bilateral treatment. Stercoral colitis may be asymptomatic or initial oophorectomy for benign ovarian cysts. Two years before symptoms may be vague. When associated with an acute the current admission, routine colonoscopy revealed abdomen, the diagnosis becomes evident with diagnostic only internal hemorrhoids. She denied smoking, drinking imaging by computed tomography (CT) scan. Diagnostic alcoholic beverages, or using street drugs. Her medications delay may result in perforation of the colon with peritonitis included calcium, vitamin D, acetaminophen, glucosa- and septic shock (1Á4). The primary differential diagnostic mine, and chondroitin sulfate. consideration is diverticulitis in a patient with left lower On physical examination, she had a pulse of 113/min, quadrant pain, and if there is right lower quadrant pain, it blood pressure of 108/72 mmHg, respiratory rate of 18/ is appendicitis (5, 6). Diverticular diseases and stercoral min, and temperature of 378C. She had left lower quadrant colitis share many pathological features (1, 2, 7, 8), and distension and tenderness without rebound tenderness. they can coexist in a patient, thus, further complicating the The rectal examination revealed impacted stool. The re- diagnostic dilemma. We report a case of stercoral perfora- maining physical examination was unremarkable. tion of the colon in a patient with diverticulosis. Laboratory studies included WBC 18,700/mL with 89.6% granulocytes, hemoglobin 13.4 g/dL, and platelet Case report count 234,000/mL. The glucose, electrolytes, bicarbonate, A 55-year-old, postmenopausal woman was presented to lactate, and renal and liver function tests were all within the emergency department with a chief complaint of left normal limits. Blood cultures were obtained, which subse- lower quadrant pain, constipation, anorexia, nausea quently were negative. CT scan of the abdomen and pelvis Journal of Community Hospital Internal Medicine Perspectives 2014. # 2014 Vijaya R. Bhatt et al. This is an Open Access article distributed under the terms 1 of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Citation: Journal of Community Hospital Internal Medicine Perspectives 2014, 4: 22898 - http://dx.doi.org/10.3402/jchimp.v4.22898 (page number not for citation purpose) Vijaya R. Bhatt et al. with oral and intravenous contrast showed abundant stool also showed prominent pinkÁtan to red, congested circular in the colon, particularly in the sigmoid colon with folds and there were multiple diverticula. Microscopic surrounding extensive infiltrative changes, wall thickening, examination showed a perforation of the colonic wall with and 6.5 cm dilation of the colon (Fig. 1). There was mucosal necrosis, acute and chronic inflammation and sigmoid diverticulosis and multiple foci of extraluminal air granulation tissue (Fig. 3). (Fig. 2). Postoperatively, the patient was continued on intrave- The patient was admitted to the medical service and nous antibiotics. The culture of the peritoneal fluid given intravenous fluids, ciprofloxacin, and metronida- was positive for extended-spectrum beta-lactamase nega- zole. Oral Colace and tap water enemas were adminis- tive Escherichia Coli sensitive to cephalosporins and tered. On the third day of hospitalization, she complained carbapenems. Her postoperative course was complicated of severe abdominal pain and had diffuse abdominal by hospital-acquired pneumonia, which was successfully tenderness with rebound tenderness and further abdom- treated with intravenous cefepime. The patient was dis- inal distension. Surgical consultation was obtained and an charged on day 11 and prescribed intravenous ertapenem emergent exploratory laparotomy was performed which for 7 days. revealed extensive fecal peritonitis. The peritoneal cavity was thoroughly lavaged and a Hartmann procedure was Discussion performed with resection of the perforated sigmoid colon, Stercoral perforation of the colon was initially de- creation of a proximal end colostomy, and closure of scribed by Berry in 1894 (9). Fewer than 90 cases were the rectal stump. The resected specimen was sent to the reported by the year 2000 (1). However, it was the cause pathology department and peritoneal fluid was sent for of 3.2% of colonic perforations in one series (1) and cultures. present in 2.2% of randomly selected autopsy ex- The pathology department received a 14.36.55.5 aminations (10). Cases of stercoral perforation of the cm segment of colon focally covered with grayÁgreen colon are likely both under-reported and are often exudate and multiple adhesions. Gross examination not recognized. With an aging population and an in- showed a 2.0-cm perforation, which was 5.5 cm from one crease in life expectancy, there are many people who resection margin. A mucosal ulceration with an overlying survive with debilitating conditions. Sick elderly people, fecaloma (hard localized accumulation of stool) was seen bed bound or minimally active, who are on multiple around the perforation. The mucosal surface of the colon medications that affect bowel motility are prone to Fig. 1. Image depicting large fecal load, sigmoid wall thickening and extensive peri-colonic infiltrative change. 2 Citation: Journal of Community Hospital Internal Medicine Perspectives 2014, 4: 22898 - http://dx.doi.org/10.3402/jchimp.v4.22898 (page number not for citation purpose) Perforation in a patient with stercoral colitis and diverticulosis
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