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Special Feature
January 1, 2007

Image of the Month—Diagnosis

Arch Surg. 2007;142(1):98. doi:10.1001/archsurg.142.1.98
Answer: Perforated Stercoral Ulcer

At laparotomy, the patient was found to have perforation of the rectum with impacted stool in the vault. There was no evidence of diverticulitis. The patient underwent resection of the affected portion of her rectum with end colostomy.

Stercoral perforation has been defined as “perforation of the large bowel due to pressure necrosis from fecal masses.”1Historically, it has been considered a relatively rare cause of colonic perforation. Fewer than 70 cases were reported in the literature before 1998.2However, the actual incidence may be higher than previously thought. In a prospective study from a university hospital, Maurer et al3found that stercoral perforation accounted for 1.2% of all emergency colorectal cases and 3.2% of all colonic perforations. The incidence may be underestimated due to misdiagnosis and lack of clear diagnostic criteria.

The median age of presentation is about 60 years with an equal gender distribution.4Often, patients have a history of chronic constipation and many present following a painful bowel movement.5Peritonitis is a common finding. Free air is often found on radiography; however, patients with rectal perforation may have retroperitoneal air as this patient did.6The rectum or sigmoid colon is the site of perforation in the vast majority of cases.7At laparotomy, fecal peritonitis is present and a fecal mass is found at the site of perforation or elsewhere within the abdominal cavity.

Although earlier series reported mortality rates of 30% to 55%, prompt exploration may decrease that rate.1,4Treatment with colostomy has a lower reported mortality rate than with primary repair.2In Maurer's series of 7 patients, all patients received colostomies and there were no in-hospital deaths.3

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Article Information

Correspondence:Laura Goetz, MD, Center for Colorectal Surgery, Department of Surgery, 2330 Post St, Suite 260, University of California at San Francisco, San Francisco, CA 94143-0144 (goetzl@surgery.ucsf.edu).

Accepted for Publication:November 30, 2005.

Author Contributions:Study concept and design: Kim. Acquisition of data: Kim. Analysis and interpretation of data: Goetz, Kim. Drafting of the manuscript: Kim. Critical revision of the manuscript for important intellectual content: Goetz. Administrative, technical, and material support: Goetz. Study supervision: Goetz.

Financial Disclosure:None reported.

References
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Serpell  JWNicholls  RJ Stercoral perforation of the colon. Br J Surg 1990;771325- 1329
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Tokunaga  YHata  KNishitai  RKaganoi  JNanbu  HOhsumi  K Spontaneous perforation of the rectum with possible stercoral etiology: report of a case and review of the literature. Surg Today 1998;28937- 939
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Maurer  CARenzulli  PMazzucchelli  LEgger  BSeiler  CABuchler  MW Use of accurate diagnostic criteria may increase incidence of stercoral perforation of the colon. Dis Colon Rectum 2000;43991- 998
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Gekas  PSchuster  MM Stercoral perforation of the colon: case report and review of the literature. Gastroenterology 1981;801054- 1058
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Dubinsky  I Stercoral perforation of the colon: case report and review of the literature. J Emerg Med 1996;14323- 325
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Rozenblit  AMCohen-Schwartz  DWolf  ELFoxx  MJBrenner  S Case reports. Stercoral perforation of the sigmoid colon: computed tomography findings. Clin Radiol 2000;55727- 729
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Maull  KIKinning  WKKay  S Stercoral ulceration. Am Surg 1982;4820- 24
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