Thursday, August 23, 2018

A perforated colon case report raises a few issues

When a medical paper is featured on the Daily Mail website, you know it’s going to be something odd.

An autistic young man with prior hospitalizations for chronic constipation and megacolon was admitted to a hospital in London, UK with a markedly distended abdomen. A CT scan showed a dilated rectum and colon with a diameter as large as 18 cm (7 inches).

He was treated conservatively for two days with laxatives. Enemas were ordered, but the patient declined. He then developed peritonitis, kidney dysfunction, mental status changes, and metabolic acidosis.

A chest x-ray showed free air under the diaphragm. A second CT scan confirmed the presence of free intra-abdominal air.

The patient underwent an emergency operation to remove part of the colon, an end-colostomy, and closure of the rectum. The paper did not mention what became of the patient after the procedure.

Some learning points were listed.

Most of them were not relevant to what went on with the management of this patient.

Here are my learning points.

No attempt was made to remove the fecal impaction manually, and colonoscopy to decompress the colon was not considered.

The patient had a history of multiple admissions for megacolon, and an 18 cm colon is at high risk for perforation. Immediate elective surgery to remove the distended portion of the colon would have been a better plan.

He refused to have enemas which wouldn’t have worked anyway and if administered improperly, may have caused the colon to perforate sooner. He was given laxatives by mouth probably making things worse by stimulating peristalsis against the fecal obstruction.

When a patient like this develops peritonitis and signs and symptoms of sepsis, a chest x-ray looking for free air is unnecessary. The repeat CT scan after the chest x-ray was even less necessary.

The paper was published in BMJ Case Reports.

16 comments:

Robert Ley said...

But tests are SO much easier than actually laying on hands and DOING something for the patient. If it were the US you could make arguments about financial recompense for multiple testing, but this was the NHS so probably no similar incentives. Just laziness. Sloth knows no boundaries.

Anonymous said...

The Daily Mail is even less credible than Lancet, if that's possible. It regularly features click-bait medical stories, usually horrendomas from dermatology, bad dietary advice, and appalling insects. Like other bad habits, reading such stories should only be indulged in private and under an assumed name. And wash your hands after.

Unknown said...

Sorry but how colonoscopy would help ?

Anonymous said...

It's called a perforated stercoral ulcer and it's not that uncommon. I've seen it twice and I'm a 4th year resident. How did this get published in BMJ?

Skeptical Scalpel said...

Robert, yes tests are easier to do.

Anon from 12:31 pm, Lancet is a respected journal.I don't understand the comparison to the Daily Mail.

Unknown, from Medscape "If the dilatation persists or worsens, colonoscopic decompression can be attempted, with consideration of placement of a decompression tube, per rectum, to the right side of the colon. Unfortunately, following decompression, the dilatation usually recurs; therefore, decompression with colonoscopy must be carefully considered, as it is not without risk in an unprepared, dilated colon." Link: https://emedicine.medscape.com/article/180955-treatment

Anon from 9:16, It could have been a stercoral ulcer or could simply have blown out due to the pressure and thin wall of the colon.

Rugger said...

Should have gone straight to the OR, no and, ifs, or buts!

Kent said...

How many doctors, particularly GI, do you know who can do a rectal exam more or less a disimpaction??

Skeptical Scalpel said...

Very few. These were surgeons who should have been able to disimpact the patient even if general anesthesia was needed.

Sidney Schwab said...

I've done a few impressive disimpactions in my office back in the day. Had to air out the room for a while before re-use. Also, I wrote about a memorable case of stercoral perforation. Didn't need much in the way of tests, either: http://surgeonsblog.blogspot.com/2006/07/memorable-patients-part-one.html

Skeptical Scalpel said...

That was quite a case.

razamo01 said...

Decompressive colonoscopy likely the best initial intervention here. After repeated admissions for disimpactions you have to offer colostomy.

Damien Joy,M.D. said...

Autistic,Multiple prior admissions...Oh,impressive that 3rd year could BE SURE of diagnosis...I would await "pathology review".(If this had been cecal, you could attribute Bernoulli's...have to assume Not the case ,as colostomy done,(not ileostomy) .With aforementioned history, patient likely with chronically dilated colon and very poor peristalsis.(No mention of bowel sounds,Hyper. or otherwise...but I would not expect b.s.,+/-,to be a prominent factor in this CHRONIC case). If he were VERY stable,I might have added a mucous fistula if there was prominent rectal dilatation,and requested pathological review for any evidence of total or segmental absence of motor deficiency.A small resection of end can be sent for review, along with the perforated segment.(Regardless,best long term Rx is "permanent"* diverting colostomy... (* this can be up for yearly? review,IF there were nothing indicating nerve involvement).This is NOT,in my opinion,a good case for dis-impaction or colonoscopy; risky or temporizing at best with prior hx. of multiple recurrences, and aforementioned complication of iatrogenic perforation. It would have been "nice" to have been told how patient fared. Regarding the site of publication...not big concern with this case report,as facts of case were not "sensationalized", nor uncommon.( Even the New York Times is error-prone!).

Anthony Foley said...

Colonoscopy would have never worked. Manual disimpaction and colonoscopy should not be mentioned in the same paragraph.

Look at the scan. This is not Ogilvie's... How will you evacuate a gallon of hard stool with a colonoscopy?

Phillip G Bailey said...

I am curious as to whether the availability of OR time or a surgical consultant was a factor. As previously stated, there is no role for laxatives from above with this presentation. Initial management is manual disimpaction if tolerated. If unable to tolerate disimpaction at bedside colostomy as primary therapy should be considered, but in the absence of an emergency there may be issues of consent. Based on history of autism spectrum disorder and dilation of rectum and sigmoid this appears to be pelvic floor dysfunction, likely psychogenic. If confirmed and unresponsive to pelvic floor PT then colostomy should be permanent.

Skeptical Scalpel said...

I don't think colonoscopy as way to remove a lot of stool would work in cases like this. Perhaps manual disimpaction followed by an attempt to decompress the dilated colon with a scope might have prevented the perforation.

However, in looking at the first CT scan again, I think the free air might have been present on admission.

Paul Logan said...

Thanks for sharing this useful information with us.

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