(P114) A Curious Case of Constipation

Chief Complaint : Constipation x 5 days, syncope

History of Present Illness : 84-year-old female with past medical history of TIA and past surgical history notable for volvulus 13 years ago, small bowel obstruction 4 years ago presenting for constipation x 5 days. In an attempt to relieve her constipation, she attempted to use Dulcolax but with no change. Today, after an episode of straining to use the bathroom, she stood up from the toilet and felt dizzy. Her son was present at the time and witnessed the patient attempting to hold herself up on the wall and then slowly collapsing to the floor. Denies fever/chills, chest pain, difficulty breathing, palpitations, leg pain, leg swelling, history of DVT/PE.

Considering our differential was focused on gastrointestinal pathology, a POCUS abdomen was conducted in an attempt to assess for bowel obstruction prior to x-ray or CT imaging.

Pertinent Physical Exam: General - Patient speaking in full sentences comfortably. Skin warm and dry.
Cardiovascular - Normal S1/S2. No murmurs, rubs, or gallops.
Respiratory - Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
Abdomen - Soft, nontender to palpation. No guarding, rigidity, or rebound.
Neurological - Equal sensation and motor function to the upper and lower extremities bilaterally. Tongue midline, no facial droop.

Pertinent Laboratory Data: VBG with no acidosis (pH 7.4), no lactate elevation (Lactate 1.0)
CBC without leukocytosis (WBC 8.3), without anemia (Hgb 12.7)
CMP without electrolyte abnormalities (Na 138, K 4.2), without Cr elevation (0.7), without transaminitis (AST 26, ALT 13)
Troponin < 0.04
ECG normal sinus rhythm without ischemic changes or prolongation of PR, QRS, or QT intervals

Case Discussion: POCUS abdomen was remarkable for a large, linear structure estimated 2.5cm in diameter posterior to the bladder (Figure 1). Within this large structure there is a hypoechoic circular structure, reminiscent of a gestational sac in the uterus (Figure 2). Given that the patient is eighty-four and postmenopausal, pregnancy was unlikely; however, similar findings in a young woman would be difficult to discern. CT abdomen/pelvis was then pursued, which revealed a markedly distended rectum with large fecal content and rectal wall thickening suggestive of stercoral colitis.
Stercoral colitis is an inflammatory colitis that can occur with colonic distension from fecal material most often seen in the elderly, bedbound, and those on chronic opioids1. A devastating consequence of stercoral colitis is ischemic pressure ulceration from the distension, which can result in focal ischemic necrosis and colonic perforation1. The most common locations of ulceration are in the sigmoid colon and the rectum2. About 27% of patients develop multiple areas of focal ulceration1.
Patients with stercoral colitis with findings concerning for peritonitis or perforation require operative management. However, in our patient with stercoral colitis but without evidence of perforation or bleeding, disimpaction is first-line management to facilitate passage of the fecal matter. Subsequent enema can be administered to soften the impaction. In the elderly, warm water enemas are preferred over sodium phosphate enemas because of the association of these kinds of enemas with hypotension, volume depletion, hyperphosphatemia, and hyperkalemia.
After disimpaction, osmotic laxatives such as polyethylene glycol and lactulose can be considered. Patients with stercoral colitis who do not show signs of peritonitis can be considered for admission for close monitoring1,3.

References and Acknowledgements (Optional): [1] Heffernan C, Pachter HL, Megibow AJ, Macari M. Stercoral colitis leading to fatal peritonitis: CT findings. AJR Am J Roentgenol. 2005 Apr;184(4):1189-93.
[2] Tokunaga Y, Hata K, Nishitai R, Kaganoi J, Nanbu H, Ohsumi K. Spontaneous perforation of the rectum with possible stercoral etiology: report of a case and review of the literature. Surg Today. 1998;28(9):937-9.
[3] Naseer M, Gandhi J, Chams N, Kulairi Z. Stercoral colitis complicated with ischemic colitis: a double-edge sword. BMC Gastroenterol. 2017 Nov 28;17(1):129.