Stercoral perforation (SP) is a rare and life-threatening acute abdominal condition. In 1972, Bauer reported 4 cases and reviewed a total of 25 cases in the literature, followed by subsequent case reports. By 1990, Serpell had compiled 64 cases from global literature between 1984 and 1990, with an additional 3 cases reported in 1995. The exact incidence of stercoral perforation remains unknown, but autopsy findings suggest an incidence greater than 5%.

bubble_chart Etiology

Chronic constipation is the main pathogenic factor of stercoral ulcers. The possible pathological mechanisms include: ① The dry fecal mass directly compresses the intestinal mucosa, leading to pressure-induced ischemic necrosis of the mucosa, which then forms ulcers or even perforation; ② The accumulation of a large amount of fecal matter in the colon causes significant dilation of the intestinal tract, increasing intraluminal pressure beyond the capillary diffusion pressure of the intestinal wall, particularly on the side opposite the mesenteric border, resulting in ischemia and necrosis of the intestinal wall; ③ Mechanical intestinal obstruction caused by fecal masses leads to elevated intraluminal pressure and direct perforation, especially when pre-existing pathological changes are present in the intestinal wall. The fecal mass causes dilation of the intestinal lumen, and when the intraluminal pressure exceeds the capillary perfusion pressure of the intestinal wall, ulcers first develop, particularly on the anti-mesenteric border, followed by perforation. Stercoral perforation most commonly occurs in the sigmoid colon and rectosigmoid junction because these areas are prone to fecal impaction; the blood supply to the distal transverse colon and mid-colon is relatively poor; and the sigmoid colon and rectosigmoid junction have the narrowest lumen, with intraluminal pressures reaching 0.49–1.81 kPa (5–100 cmH₂

bubble_chart Pathological Changes

There are two types of fecal ulcers: ① occurring at a site proximal to an obstructive lesion; ② formed by direct compression of fecal matter. The shape of the ulcer often resembles that of the impacted fecal mass. The depth of the ulcer exceeds the mucous membrane, and it is often multiple. Perforation occurs in the center of the ulcer, presenting as round or oval. Histology reveals ischemic necrosis and inflammatory reactions. Grinvalsky described that the intestinal mucosa is flattened by fecal compression, leading to ischemic necrosis and the formation of single or multiple ulcer lesions, whose contours resemble the shape of the adjacent fecal mass. Microscopically, mucosal denudation, tissue ischemic necrosis, and varying degrees of inflammatory reactions are observed. These pathological features are the primary basis for distinguishing SP from idiopathic colonic perforation. Clinically, both conditions have a history of constipation, but the latter presents with a tear-like perforation, everted intestinal mucosa, and normal histopathological findings.

Due to the presence of a large amount of fecal matter in the colon with fecal perforation, some patients have multiple perforations (21%). The inflammatory and necrotic processes are not limited to the perforation area, and the perforation remains open, making conservative treatment difficult to cure.

bubble_chart Clinical Manifestations

SP commonly occurs in the elderly. Abdominal pain typically begins in the lower left abdomen and gradually spreads to the entire abdomen. Bowel movements often cause a sudden worsening of abdominal pain, and by the time of medical consultation, peritoneal signs are already present. Approximately one-third of patients may have palpable abdominal masses due to large fecal impactions. Half of the patients show free air under the diaphragm on abdominal X-ray films, and sometimes fecal shadows or calcified fecal masses can also be seen. Diagnostic abdominal paracentesis helps determine the nature of peritonitis. SP lacks specific clinical manifestations, and the preoperative diagnosis rate is low, with Serpell reporting it as only 11%. The key to improving the preoperative diagnosis rate lies in a thorough understanding of the condition. Serpell suggests that when elderly patients with peritonitis have a history of chronic constipation, palpable abdominal masses, free air under the diaphragm, and fecal shadows on abdominal X-ray films, fecal perforation of the colon should be highly suspected.

Once SP occurs, early surgery is necessary. There are three main methods for managing perforated colon, depending on the degree of peritoneal contamination and the patient's condition: ① resection of the affected colon segment with proximal colostomy; ② exteriorization of the perforated colon segment with colostomy; ③ repair and closure of the perforation with proximal colostomy. Most scholars advocate early exteriorization of the perforated colon segment with colostomy because the procedure is simple and safe, especially when the patient's condition is poor and surgical time is limited. If the perforation site is too low to allow exteriorization, repair and closure of the perforation with proximal colostomy is performed instead. Since the 1980s, with a deeper understanding of the disease, resection of the affected colon segment with proximal colostomy has become the preferred choice, followed by exteriorization colostomy. Serpell and Guyton compared the outcomes of several surgical methods and found that, in terms of both postoperative mortality and complication rates, resection of the affected colon segment with proximal colostomy had the lowest incidence. Serpell noted that colonic fecal ulcers are often multiple, and sometimes inflammation and necrosis affect an entire segment of the intestine. Additionally, the proximal colon is often filled with fecal matter and highly distended. Therefore, resection of the affected colon segment with proximal colostomy can reduce the risk of recurrent perforation and enteric fistula. Moreover, removing the highly distended colon also helps improve constipation. Guyton emphasized the importance of carefully examining the serosal surface of the entire colon during surgery. He found that fecal ulcers often lie beneath areas of serosal tears, and any segment with serosal tears should be resected.

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The prognosis of this disease is poor, with most early postoperative deaths resulting from severe septic toxic shock. The poor prognosis is associated with the following factors: ① The patient is of advanced age and accompanied by other internal diseases; ② The patient's general condition rapidly deteriorates once perforation occurs; ③ By the time of surgery, the patient already has peritonitis, and the condition is critical. The key to improving the prognosis of this disease lies in enhancing awareness of the disease, achieving early diagnosis, and performing timely surgery.

Serpell reviewed 64 cases of SP reported in the literature, including 29 males and 35 females. The average age was 60 years (range: 16–89). Chronic constipation was present in 39 cases (61%) prior to onset. Substances causing constipation included aluminum hydroxide preparations in 10 cases, regular codeine use in 5 cases, narcotic addiction in 1 case, self-prepared clay mixtures in 2 cases, amitriptyline or other sedatives causing constipation in 5 cases, and paper pica in 1 case. Additionally, there were 5 cases of chronic kidney failure and 3 cases of kidney transplantation. Clinical manifestations included localized peritonitis in 13 cases (20%), diffuse peritonitis in 51 cases (80%), palpable abdominal masses in 15 cases, and palpable fecal masses on rectal examination in 4 cases. Only 7 cases (11%) were correctly diagnosed preoperatively. Plain chest and abdominal X-rays were performed in 43 cases, with pneumoperitoneum observed in 23 cases (53%). The most common site of perforation was the sigmoid colon (47%), followed by the rectosigmoid junction (3%), cecum (9%), transverse colon (7%), descending colon (5%), and splenic flexure (2%). Single perforations accounted for 79%, while the rest were multiple perforations. Except for one case, all perforations occurred along the mesenteric border of the colon. The colon was filled with hard fecal masses in 40 cases (63%). Conservative treatment was administered in 12 cases (19%), with diagnosis confirmed at autopsy. The remaining 52 cases underwent exploratory laparotomy, with 18 postoperative deaths (35%). The mortality rate for conservative treatment was 47%.

Three cases of SP were reported, all male, aged 59–74 years, hospitalized for acute abdominal pain. Two cases developed symptoms after defecation, and one had a history of constipation. All underwent emergency surgery, with perforations located in the mid-to-distal sigmoid colon. One case underwent exteriorization of the bowel and died 3 hours postoperatively; one underwent perforation repair with sigmoid colon bridge stoma; and one underwent left hemicolectomy with transverse colostomy, all recovering well postoperatively.