Introduction:
Eliminating excess and the toxic byproduct of the body is an essential procedure to keep the body healthy. Stool or feces is a product that eliminates excess and undigested food. Also, some metabolic byproducts are eliminated by stool. It is eliminated from the body through the digestive tract. Unable to eliminate stool and its retention in the body is known as constipation. A huge number of people around the world are suffering from this condition. Through lifestyle modifications, such problems can be solved. But certain cases of constipation may cause serious complications like stercoral ulcers. This serious complication may cause life-threatening situations.
What Is Constipation?
Constipation is difficulty in passing a sufficient amount of stool. It is characterized by passing the bowl less than three times a week. Around 15 percent of the world's population complains of constipation. The causative factors for constipation are:
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Functional (Non-Organic) or Retentive: This type of constipation is developed due to excessive withholding behaviors.
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Anatomic Causes: Obstruction in the gastrointestinal tract or anatomical malformations in the anal tract like anal stenosis or atresia (congenital malformation characterized by narrowing of the anas), anteriorly displaced anus (anterior positioning of the anas), and imperforate anus (a congenital condition in which opening of the anas is blocked) is responsible for such conditions.
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Intestinal Nerve Abnormality-Related Causes: In this type, abnormality of neural function is associated with gastrointestinal abnormalities. Conditions like Hirschsprung disease (nerve cells in the muscular part of the colon are missing), tethered cord (neurological disorder in which tissue attachment limits the movement of the spinal cord), and spina bifida (a type of neural tube defect) are responsible.
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Drugs: Different drugs like anti-cholinergic drugs and excessive vitamin D intake may cause constipation.
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Metabolic and Endocrine Disorders: These conditions are responsible for impaired neurological function and are responsible for constipation. Such conditions are hypothyroidism, diabetes, hypokalemia (low potassium level in the blood), and hypercalcemia (increased calcium level in the blood).
Other than this, factors like less water intake, consumption of less fibrous foods, excessive use of laxatives, stress, and no body movement are responsible for constipation. Constipation can be acute or chronic. Acute constipation is sudden in onset and generally less severe. Chronic constipation is a serious condition associated with various risk factors such as increased age, immobility, hypertension, colonic disorders, and malnutrition. Chronic constipation leads to colon inflammation, known as stercoral colitis. This inflammation leads to the formation of stercoral ulcers.
What Is Stercoral Ulcer?
Stercoral ulcers are colonic ulcers formed due to pressure, irritation, and inflammation caused by prolonged constipation. This rare condition is mainly seen in the retro sigmoid colon area.
What Are the Risk Factors of Stercoral Ulcer?
Chronic constipation is the main cause of stercoral ulcers. The associated risk factors are:
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Older age group.
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Bedridden patient.
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Consumption of a less fibrous diet.
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Obstruction is caused by polyps, adhesion of the structures due to surgery, scar tissue, hernias, and colonic cancer. Intussusception or malpositioning of the intestinal structures due to sliding over one another is also a major cause of constipation.
What Is the Pathophysiology of Stercoral Ulcer?
Chronic constipation causes accumulation and stagnation of fecal matter. Increased volume of fecal matter causes impaction and deformation of the colon. Gradually, these masses form fecaliths, becoming more dehydrated and hard and forming fecaloma. These masses compress the intestinal wall and vasculature. These compressions are responsible for the ischemic conditions in the intestinal tissue. Gradual ischemia causes cell death and the formation of ulcers.
These ulcers formed areas adjacent to the fecaloma where the maximum pressure is. These are also found in the convex border of the mesentery (intestinal wall) or antimesenteric side of the bowel due to the less vasculature of this portion.
What Are the Symptoms of Stercoral Ulcer?
Patients complain of:
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Chronic constipation and not passing of stool for several days.
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Abdominal pain and abdominal cramps.
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Distention of abdomen.
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Nausea and vomiting.
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Rectal bleeding.
What Are the Complications of Stercoral Ulcer?
The main complication associated with this problem is perforation. Ulcers with gradual ischemic conditions cause necrosis of the intestinal wall and its perforation. In severe cases, this may cause compression of an entire segment of the intestinal wall due to the dilatation of the colon. As a result, veins are compressed, and outward blood flow is obstructed. Ischemic colitis is developed in such conditions due to intramural edema (accumulation of fluid in between layers of the intestinal wall) and arterial compromise (blockage in the artery).
What Are the Diagnostic Methods of Stercoral Ulcer?
The diagnosis of such conditions can be made through history. But the intestinal lumen condition can only be made through CT and X-rays.
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Elimination of the perforation is a priority in such situations to rule out emergency conditions. The patient's chest radiograph should be taken in the upright position to detect free air and peritonitis (the layer between the abdomen and chest is inflamed).
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CT abdomen and pelvis with intravenous contrast medium is the most commonly used diagnostic method employed in this condition. Fecalomas appear as radioopaque masses in the scan. Focal thickening of mucosal wall suggestive of edema or ulceration. The edematous bowel appears as a mucosal discontinuity on CT imaging. This is because of the reduced uptake of contrast material due to the limited blood supply. In uncomplicated cases of fecalomas, impaction the mucosal thickening is not present.
How to Treat Stercoral Ulcer?
If perforation is not present, it is managed through manual disimpaction via the rectum. Sometimes it is done through endoscopically monitored disimpaction. If perforation is present, surgical intervention is the only option. In such cases, resection of the affected bowel, colostomy (removal of one portion of the colon), and Hartmann pouch (surgical procedure in which part of colon and rectum is removed) are the procedures to be considered. Patients with perforation often show signs of sepsis because of contamination of pathogens in the body fluid. Such cases should be managed through antibiotic infusions.
Conclusion:
Chronic constipation may cause serious side effects. Stercoral colitis in such cases may develop from prolonged impaction of feces. This inflammation of the colon may lead to stercoral ulcers. This is a potentially life-threatening condition that may cause ischemic necrosis of the intestinal wall. Modern diagnostic methods like CT scans can be used to detect such conditions.
