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Case 8-1: Severe constipation

Patient Presentation

A 23-year-old presented with abdominal pain and constipation. He had a history of stooling every 2 to 4 weeks for most of his life, and he had one episode of constipation requiring rectal disimpaction 1 year prior to this visit.

Figure 8-1.

Contrast-enhanced abdominal CT scan (axial view). WA = massive colonic dilatation from stool

Figure 8-2.

Contrast-enhanced abdominal CT scan (coronal view). WA = massive colonic dilatation from stool

Clinical Features

The patient’s abdomen was significantly distended with a firm mass and mild tenderness to palpation. The mass could be indented or pushed slowly away by the examining physician’s hand.

Differential Dx

  • Severe constipation

  • Cancer

  • Obstruction

Emergency Care

Contrast-enhanced abdominal computed tomography (CT) scan in axial and coronal plane demonstrated massive colonic dilatation from impacted stool. The patient was admitted for further management.


The patient went to the operating room on two separate occasions for manual per-rectal disimpaction. Biopsies were taken and were negative for Hirschsprung disease. The patient was discharged with a bowel regimen for constipation. He returned 1 year later with a very similar presentation, again requiring intraoperative disimpaction.

Key Learning Points

  • Stercoral perforation occurs when an intraluminal object, most commonly hardened feces, exerts pressure on the bowel wall, causing a locally inflamed and ischemic bowel wall, leading to rupture from local necrosis. It carries a high morbidity and mortality.

Further Reading

Andromanakos  NP, Pinis  SI, Kostakis  AI. Chronic severe constipation: current pathophysiological aspects, new diagnostic approaches, and therapeutic options. Eur J Gastroenterol Hepatol. 2015;27(3):204–214.  [PubMed: 25629565]
Chiarioni  G. Biofeedback treatment of chronic constipation: myths and misconceptions. Tech Coloproctol. 2016;20(9):611–618.  [PubMed: 27450533]
Mosinska  P, Salaga  M, Fichna  J. Novel investigational drugs for constipation-predominant irritable bowel syndrome: a review. Expert Opin Investig Drugs. 2016;25(3):275–286.  [PubMed: 26765585]
Thayalasekeran  S, Ali  H, Tsai  H. Novel therapies for constipation. World J Gastroenterol. 2013;19(45):8247–8251.  [PubMed: 24363515]
Wood  RJ, Yacob  D, Levitt  MA. Surgical options for the management of severe functional constipation in children. Curr Opin Pediatr. 2016;28(3):370–379.  [PubMed: 26963948]

Case 8-2: Colovesical fistula

Patient Presentation

A 73-year-old presented with a 2-week history of abdominal pain as well as passing air in his urine stream. The urine was also described as dark and foul smelling.

Figure 8-3.

Pelvis x-ray. WA = air in the bladder

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