Gastroenterology fellow Walter Reed National Military Medical Center Rockville, MD
Jared S. Magee, DO, MPH1, Patrick Young, MD2; 1Walter Reed National Military Medical Center, Rockville, MD; 2Walter Reed National Military Medical Center, Bethesda, MD
Introduction: Chronic constipation is a commonly encountered complaint among adult patients. Slow transit constipation is a form of functional constipation that is generally managed with a low fiber diet and stimulant laxatives. This can be a difficult concept for patients to appreciate given fiber supplementation is recommended for most forms of constipation. Here we describe a case of stercoral perforation following resumption of a high fiber diet after colonoscopy in a patient with slow transit constipation.
Methods: 64 year old female with a history of chronic slow transit constipation presented to the emergency department (ED) for abdominal and rectal pain over the course of 1 day. 2 weeks prior, the patient had completed a screening colonoscopy. Despite standard bowel prep, the initial colonoscopy was aborted due to solid stool throughout the rectum and sigmoid colon. She repeated the prep and had a second colonoscopy the following day with no detected abnormalities. Following the procedure, the patient initiated a very high fiber diet of 60 gm/day as she believed this would help her “get back to normal after her prep”. She had no bowel movement through the time of presentation to the ED. Initial evaluation revealed a normal CMP and CBC. Abdominal X-ray showed pneumoperitoneum. A CT of the abdomen demonstrated thickening of the sigmoid colon with a large stool burden and concern for a sigmoid wall perforation. She was admitted to the hospital and general surgery consulted. After initial conservative measures failed, she was taken for exploratory laparotomy. A 3cm perforation secondary to a stercoral ulcer and 7cm fecaloma were found in the sigmoid colon. She underwent sigmoid resection and end colostomy with Hartman’s pouch. The remainder of the patient’s hospital course was uncomplicated, and she was discharged home with intention of colostomy reversal as an outpatient. Discussion: Stercoral perforation is an uncommon but life-threatening complication of a fecal impaction. Our patient had assumed that she needed to double her daily fiber intake to accommodate her lack of fiber during her bowel prep for colonoscopy. In the setting of her slow transit constipation, the excess fiber led to development of a fecaloma and perforation. This case demonstrates the need to educate patients on the potential harms of excess fiber and discuss a gradual return of fiber to the diet after colonoscopy. Our goal is to share this uncommon experience so others may prevent harm from misunderstanding.
Disclosures: Jared Magee indicated no relevant financial relationships. Patrick Young indicated no relevant financial relationships.