Cause
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| Stercoral ulcer | |
|---|---|
| Specialty | Gastroenterology |
| Symptoms | Hematochezia, Abdominal pain, Fever |
| Causes | Constipation, Stercoral Colitis, Chagas disease, Hirschsprung's disease |
| Diagnostic method | CT scan |
| Prevention | Treatment of the causes of constipation |
Stercoral ulcer is an ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation due to a large bowel obstruction, damage to the autonomic nervous system, or stercoral colitis. It is most commonly located in the sigmoid colon and rectum. Prolonged constipation leads to production of fecaliths, leading to possible progression into a fecaloma. These hard lumps irritate the rectum and lead to the formation of these ulcers. It results in fresh bleeding per rectum (i.e. hematochezia). These ulcers may be seen on imaging, such as a CT scan but are more commonly identified using endoscopy, usually a colonoscopy. [1] Treatment modalities can include both surgical and non-surgical techniques.
Typical patients will present with a history of constipation, likely chronic constipation. Patient populations vulnerable to chronic constipation include, but are not limited to, the elderly, persons with dementia, those with damage to the autonomic nervous system, infectious diseases, or intestinal vascular compromise. Some patients, due to their condition, may have limitations in reporting their symptoms. Typical symptoms can include abdominal pain, abdominal distention, abdominal cramping, nausea, vomiting, fever, rectal bleeding, and possible bowel perforation. [2] Patients that develop bowel perforation may present in an acute state with severe abdominal pain and signs of perforation, such as abdominal distention, guarding and rigidity, and air in the abdominal cavity.[ citation needed ]
Stercoral ulcers can lead to a complication known as stercoral colitis. Stercoral colitis is a relatively rare form of inflammatory colitis that can develop as a result of chronic constipation leading to the formation of hardened stool, known as fecaloma. Fecalomas can then lead to distention, possibly causing focal necrosis and possibly ulceration. Additional distention in the area can lead to compromise of the vascular supply, leading to intestinal ischemia [2] This form of colitis can be due to a wide range of etiologies, coinciding with most causes of constipation. Other etiologies range from a stroke, intestinal vascular compromise, or any other damage to the autonomic nervous system to more rare diseases such as Chagas disease and Hirschsprung's disease.[ citation needed ]
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Ensuring a proper diagnosis involves a variety of tools by the clinician. An efficient abdominal exam, along with a rectal exam aids in diagnosis. Typically patients will have tenderness to palpation on exam. Rebound tenderness or guarding may present with perforation of the ulcer with air leaking into the abdomen. In these patients, their exam may be far more acute with abdominal rigidity and need for immediate surgical intervention. Additionally, a rectal exam may reveal stool present in the rectal vault, pointing to the fact that constipation has been or is still present. These patients may even have blood on their rectal exam, due to passing small amounts of stool around the ulcer and adjacent fecaloma. [2]
Patients may have unstable vital signs if they have been having rectal bleeding, have developed stercoral colitis, and/or have had a perforation of the ulcer. These vital sign changes may be an acute fever, elevated heart rate, and/or decreased blood pressure. Laboratory evaluation may not be as specific in pointing to a diagnosis. Patients may have non-specific leukocytosis with elevated acute phase reactants. However, these are neither specific nor sensitive so the clinician must take into account all aspects of the patient's illness to reach the diagnosis. If a patient presents with severe symptoms it may be useful to order blood cultures and preoperative labs such as type and screen and coagulation testing. [2]
Imaging studies have been shown to be a key aspect in diagnosing patients with stercoral ulcers and stercoral colitis. Patient status on presentation is important to take into consideration when deciding what imaging study to order. Patients who are acutely ill and showing signs of perforation will need an upright Chest x-ray to determine if there is free air in the peritoneum. The imaging study of choice is an CT scan of the abdomen with IV contrast, considering the patient's renal function is adequate. Findings that can be seen are fecal impaction with dilation of the rectosigmoid junction commonly, but any part of the colon can be dilated. Additionally, fecalomas may be seen as masses in the colon. In the case of ulceration, the part of the colon adjacent to the fecaloma will be thickened. This thickening of the bowel will help differentiate from stercoral colitis and stercoral ulcer from fecal impaction as the colon is typically not thickened in cases of fecal impaction. [2]
Treatment of these patients is typically dependent on a case-to-case basis as the overall patient presentation has to be considered. If the patient presents in an acutely ill state with possible sepsis or shock, they will need adequate IV fluid hydration with possible broad-spectrum antibiotics. Additionally, these patients may need surgery if perforation has occurred. Patients without these symptoms should be managed conservatively with either manual or endoscopically guided fecal disimpaction. A bowel regimen should also be started to ensure that bowel movements become normal. Opioid pain medication should be avoided as these medications can slow colonic motility and possibly worsen constipation. The key to management and prognosis is identifying the cause or causes of the underlying constipation. Patients should be encouraged to increase fiber, fluids, and fruits in their habits. Osmotic and stimulant laxatives can also be considered to aid patients if they have trouble making the necessary changes to their diet. [2]
Ulcerative colitis (UC) is one of the two types of inflammatory bowel disease (IBD), with the other type being Crohn's disease. It is a long-term condition that results in inflammation and ulcers of the colon and rectum. The primary symptoms of active disease are abdominal pain and diarrhea mixed with blood (hematochezia). Weight loss, fever, and anemia may also occur. Often, symptoms come on slowly and can range from mild to severe. Symptoms typically occur intermittently with periods of no symptoms between flares. Complications may include abnormal dilation of the colon (megacolon), inflammation of the eye, joints, or liver, and colon cancer.
Defecation follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus or cloaca. The act has a variety of names ranging from the common, like pooping or crapping, to the technical, e.g. bowel movement, to the obscene (shitting), to the euphemistic, to the juvenile. The topic, usually avoided in polite company, can become the basis for some potty humor.
Hematochezia is a form of blood in stool, in which fresh blood passes through the anus while defecating. It differs from melena, which commonly refers to blood in stool originating from upper gastrointestinal bleeding (UGIB). The term derives from Greek αἷμα ("blood") and χέζειν. Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper gastrointestinal bleed. The difference between hematochezia and rectorrhagia is that rectal bleeding is not associated with defecation; instead, it is associated with expulsion of fresh bright red blood without stools. The phrase bright red blood per rectum is associated with hematochezia and rectorrhagia.
A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.
Diverticulosis is the condition of having multiple pouches (diverticula) in the colon that are not inflamed. These are outpockets of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. Diverticula do not cause symptoms in most people. Diverticular disease occurs when diverticula become clinically inflamed, a condition known as diverticulitis.
Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum; and the accessory organs of digestion, the liver, gallbladder, and pancreas.
Rectal tenesmus is a feeling of incomplete defecation. It is the sensation of inability or difficulty to empty the bowel at defecation, even if the bowel contents have already been evacuated. Tenesmus indicates the feeling of a residue, and is not always correlated with the actual presence of residual fecal matter in the rectum. It is frequently painful and may be accompanied by involuntary straining and other gastrointestinal symptoms. Tenesmus has both a nociceptive and a neuropathic component.
Colic in horses is defined as abdominal pain, but it is a clinical symptom rather than a diagnosis. The term colic can encompass all forms of gastrointestinal conditions which cause pain as well as other causes of abdominal pain not involving the gastrointestinal tract. What makes it tricky is that different causes can manifest with similar signs of distress in the animal. Recognizing and understanding these signs is pivotal, as timely action can spell the difference between a brief moment of discomfort and a life-threatening situation. The most common forms of colic are gastrointestinal in nature and are most often related to colonic disturbance. There are a variety of different causes of colic, some of which can prove fatal without surgical intervention. Colic surgery is usually an expensive procedure as it is major abdominal surgery, often with intensive aftercare. Among domesticated horses, colic is the leading cause of premature death. The incidence of colic in the general horse population has been estimated between 4 and 10 percent over the course of the average lifespan. Clinical signs of colic generally require treatment by a veterinarian. The conditions that cause colic can become life-threatening in a short period of time.
A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or significant pain when the abdomen is touched.
A fecal impaction or an impacted bowel is a solid, immobile bulk of feces that can develop in the rectum as a result of chronic constipation. Fecal impaction is a common result of neurogenic bowel dysfunction and causes immense discomfort and pain. Its treatment includes laxatives, enemas, and pulsed irrigation evacuation (PIE) as well as digital removal. It is not a condition that resolves without direct treatment.
Proctitis or anusitis is an inflammation of the anus and the lining of the rectum, affecting only the last 6 inches of the rectum.
Megacolon is an abnormal dilation of the colon. This leads to hypertrophy of the colon. The dilation is often accompanied by a paralysis of the peristaltic movements of the bowel. In more extreme cases, the feces consolidate into hard masses inside the colon, called fecalomas, which can require surgery to be removed.
Blood in stool looks different depending on how early it enters the digestive tract—and thus how much digestive action it has been exposed to—and how much there is. The term can refer either to melena, with a black appearance, typically originating from upper gastrointestinal bleeding; or to hematochezia, with a red color, typically originating from lower gastrointestinal bleeding. Evaluation of the blood found in stool depends on its characteristics, in terms of color, quantity and other features, which can point to its source, however, more serious conditions can present with a mixed picture, or with the form of bleeding that is found in another section of the tract. The term "blood in stool" is usually only used to describe visible blood, and not fecal occult blood, which is found only after physical examination and chemical laboratory testing.
Lower gastrointestinal bleeding (LGIB) is any form of gastrointestinal bleeding in the lower gastrointestinal tract. LGIB is a common reason for seeking medical attention at a hospital's emergency department. LGIB accounts for 30–40% of all gastrointestinal bleeding and is less common than upper gastrointestinal bleeding (UGIB). It is estimated that UGIB accounts for 100–200 per 100,000 cases versus 20–27 per 100,000 cases for LGIB. Approximately 85% of lower gastrointestinal bleeding involves the large intestine, 10% are from bleeds that are actually upper gastrointestinal bleeds, and 3–5% involve the small intestine.
Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply (ischemia). Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified.
In the anatomy of humans and homologous primates, the descending colon is the part of the colon extending from the left colic flexure to the level of the iliac crest. The function of the descending colon in the digestive system is to store the remains of digested food that will be emptied into the rectum.
Rectal discharge is intermittent or continuous expression of liquid from the anus. Normal rectal mucus is needed for proper excretion of waste. Otherwise, this is closely related to types of fecal incontinence but the term rectal discharge does not necessarily imply degrees of incontinence. Types of fecal incontinence that produce a liquid leakage could be thought of as a type of rectal discharge.
Solitary rectal ulcer syndrome or SRUS is a chronic, benign disorder of the rectal mucosa. It commonly occurs with varying degrees of rectal prolapse. The condition is thought to be caused by different factors, such as long term constipation, straining during defecation, and dyssynergic defecation. Treatment is by normalization of bowel habits, biofeedback, and other conservative measures. In more severe cases various surgical procedures may be indicated. The condition is relatively rare, affecting approximately 1 in 100,000 people per year. It affects mainly adults aged 30–50. Females are affected slightly more often than males. The disorder can be confused clinically with rectal cancer or other conditions such as inflammatory bowel disease, even when a biopsy is done.
Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.
Colonic ulcer can occur at any age, in children however they are rare. Most common symptoms are abdominal pain and hematochezia.