Marked faecal loading of the distal colon

Case contributed by Zach Drew


Chronic constipation in the setting of lifelong obstructive defaecation, previous bowel obstructions secondary to adhesions and developmental issues (unclear underlying aetiology). Likely underlying diagnosis of Hirschprung disease.

Patient Data

Age: 20 years
Gender: Male

Severe faecal loading projecting over the left side of the abdomen and into the pelvis likely represents a massively faecally loaded descending/sigmoid colon. Descending colon measures up to 16 cm in diameter. Further mild faecal loading of right colon.

Gross distension of the rectum, sigmoid and distal descending colon due to faecal material, in the setting of long-standing colonic dilatation. Gaseous distension of the small bowel. The rectum, sigmoid colon and descending colon are grossly distended with low density faecal material. The rectum measures 8.5 cm in transverse dimension. Nasogastric tube in situ, the tip within the stomach. Abnormal location of the duodenum which curves to the right side of the abdomen rather than crossing the midline. Gaseous distension of the centrally located bowel loops, likely small bowel. Small bowel is difficult to assess further.

Abnormal location of the duodenum with possible congenital midgut malrotation.

Case Discussion

Patient was experiencing only intermittent abdominal pain and bloating, opening bowels on a daily basis using up to 24 scoops of Osmolax (Australian brand of stool softener) per day. Decision made for conservative management given previous surgery complicated by bowel obstruction secondary to adhesions.

Complex past medical history for this patient included autism, cerebral palsy, epilepsy, microcephaly, and suspected Hirschsprung disease (but with indeterminate rectal biopsy results).

Hirschsprung disease is the most common cause of neonatal colonic obstruction, and typically presents in neonatal/young children (more commonly boys). It is characterised by a short segment of colonic aganglionosis or neural migratory failure. Potential radiographic findings are typically that of bowel obstruction, and in protracted cases marked dilation can develop, which can be complicated by perforation or enterocolitis.

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