What causes sudden fatal abdominal pain in elderly patients with chronic constipation? How to identify as soon as possible?

Case data

The patient, a 66-year-old male, presented with sudden severe abdominal pain for 4 hours
.
Patients have a history of
chronic constipation.

Vital signs: body temperature 38.
6 ° C; Pulse 98 beats / min; Breathe 23 breaths / min; blood pressure 107/86 mmHg; The blood oxygen saturation under indoor air is 80%.

Physical examination: abdominal distension, tenderness, signs of
peritonitis.

CT of the abdomen shows a pneumoperitoneum sign in the upper abdomen, a large amount of feces around the sigmoid colon, and several large fecal nodules at the distal end of the sigmoid colon (see figures A and B arrows).

Figures A, B

Q: What is the most likely diagnosis for a patient?

The answer is revealed: fecal peritonitis caused by perforation of the sigmoid colon

To relieve symptoms of septic shock, the patient was immediately subjected to emergency surgery
.
During surgery, a large amount of feces and food residue was found in the pelvis, especially around the sigmoid colon (Figure C).

Since these feces and food scraps cannot be sucked out of the abdominal cavity, laparoscopic surgery is converted to laparotomy
.
An oval perforation > 2 cm in diameter was found on the opposite edge of the sigmoid mesangium (Figure D
).
Finally, a colostomy
was performed.

Figures C, D

Postoperative pathological examination suggests tissue inflammation
.
These features are consistent with the diagnosis
of fecal peritonitis due to sigmoid fecal perforation.
Fecal colonic perforation is rare, and chronic constipation is a major causative factor that can be easily overlooked
.

Its compressive necrotic perforation is caused by hard fecal stagnation, which occurs in the distal 1/3 of the colon
.
Although emergency surgery is possible, mortality is high
.

This patient presents with 4 features of fecal peritonitis due to fecal perforation in the colon: chronic constipation, fecal peritonitis, and oval perforation
of the opposite edge of the mesentery.

These features suggest an urgent and fatal condition that can easily lead to septic shock
.
Typical imaging findings of CT indicate the need for surgery as soon as possible
.
Although the patient was transferred to the intensive care unit immediately after surgery, he died of severe sepsis and septic shock after 2 days of treatment
.

Knowledge Class: Colon Pecal Perforation

Colon fecal perforation is a rare fatal acute abdomen, accounting for about 3.
2% of all colon perforations, the disease is more common in the elderly, 61~81% of patients have a history of constipation, clinicians often misdiagnose
due to insufficient understanding.

Colon fecal perforation is mostly manifested as local or diffuse peritonitis, and the perforation site is mostly located in the left colon or upper rectum, which may be related to
the special physiological and anatomical factors of the sigmoid colon.
Because the colon contents contain a large number of bacteria, once perforated, resulting in acute diffuse peritonitis, patients are easily affected by bacterial toxin absorption to produce septic shock disease leading to multi-organ failure, and the mortality rate can be as high as 35%~47%.

Therefore, once the disease is diagnosed, it should be treated with surgery as soon as possible
.

Patients with the following conditions should first consider the possibility of this disease: (1) age > 60 years old, accompanied by a history of chronic constipation, often have dull abdominal pain, history of enteritis; (2) Sudden abdominal pain, abdominal tenderness, rebound tenderness and muscle tension or palpation of masses
.
(3) Abdominal CT/X-ray examination showed that the diaphragm was separated from the gas or fecal stone shadow, and the abdominal effusion and intestinal tube were dilated
.
Abdominal puncture extracts purulent, fecal fluid, food scraps
.

References:

1.
Huang X, Huang L.
Sudden fatal abdominal pain in an old man with chronic constipation[J].
Gastroenterology, 2022, 163(4): e14-e15.

2.
JIANG Zhiling, DENG Guiying, FU Dan.
A case of chronic colonic fecal perforation [J] .
Chinese Journal of Digestive Endoscopy, 2011, 28(6): 329-329.

3.
YAN Jiangang, GENG Di, ZHOU Ciping, et al.
Clinical analysis of colorectal perforation in the elderly[J].
Yunnan Medical Journal,2021,42(3):280-281.