Presentation
Long history of constipation. Acute left lower quadrant pain. Raised inflammatory markers. tenderness on examination.
Patient Data
Large volume of solid fecal matter within the colon. Free gas in sigmoid mesentery along with free gas extending up the retroperitoneum. Small volume of free fluid in the pelvis. No abscess. No diverticulosis. Some reactive small bowel thickening in the pelvis. Heavy vascular calcification. Appearances consistent with stercoral colitis complicated by perforation.
HISTOLOGY REPORT
Specimen: Sigmoid colon.
Clinical Details: Laparotomy and Hartmann's for perforated sigmoid colon. Fecal peritonitis.
Macroscopic: 240mm length of large bowel full of impacted feces. Perforation site 100 mm from nearest margin.
Microscopic: At the site of perforation there is an area of acute transmural ischemic necrosis of the large bowel wall with inflammation in the adjacent fat and an inflammatory serosal reaction. Vessels are congested but there is no vasculitis and no diverticula are noted. Sampling from the mesentery shows weakly reactive lymph nodes and congested vessels. There is no vascular occlusion. One resection margin is suboptimally oriented but the other shows no significant pathology.
Conclusion: Sigmoid colectomy - perforated sigmoid colon with fecal impaction (stercoral perforation).
Case Discussion
Chronic pressure on the bowel wall by the hard inspissated fecal matter may lead to ischemia, necrosis and finally perforation. This case illustrates how perforation from the sigmoid colon can lead to gas within the retroperitoneal space as it communicates with the extraperitoneal space that is contiguous with the sigmoid mesocolon.
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