A Case of Stercoral Perforation Detected on CT Requiring Proctocolectomy in a Heroin-Dependent Patient

Abstract

Stercoral perforation of the colon is rare but carries with it significant morbidity and mortality. Stercoral perforation usually occurs in elderly, immobile patients with chronic constipation. In this manuscript, we report the case of stercoral perforation in a patient due to chronic heroin dependence. We report the case of a 56-year-old male patient with stercoral perforation, diagnosed by computed tomography, secondary to heroin dependence, requiring proctocolectomy and an end ileostomy. There are very few reports in the literature describing cases of stercoral perforation and questions have been asked about the importance of preoperative cross-sectional imaging. In our case, the diagnosis of stercoral perforation was made only on CT. Although this is not the first such case to be reported, it is significant as preoperative CT imaging was influential not only in determining the aetiology of the abdominal distension seen on the plain film, but also in detecting the pneumoperitoneum which was not evident clinically or on plain radiographs.

Figure 1

Plain preoperative abdominal radiograph.

Figure 2

Plain preoperative erect chest radiograph.

Figure 3

Sagittal MPR CT images with soft tissue windows on the left and lung windows on the right. There is gross chronic colonic distension with faecal loading down to the low rectum. The arrow shows faeces in a capacious sigmoid colon. No free gas on the film.

Figure 4

Axial CT images on soft tissue windows showing the anterior ascending colon perforation site (arrow). The ascending colon has collapsed a little relative to the distal bowel. No definite intramural gas in the wall. There is right-side pneumoperitoneum (arrowhead).

Figure 5

Axial CT image on lung windows (small field of view) confirming the perforation site (arrow).

Figure 6

Axial CT images on lung windows confirming small pockets of free gas adjacent to the perforation site.