Today I reviewed, linked to, and embedded “Patient dies of perforated colon ulcer due to stercoral colitis (SC) from May 2023 Medical Malpractice Insights: Learning From Lawsuits.*
The patient’s 31% bands on CBC would, I think, warrant a CT scan of the abdomen and pelvis.
Here are links to two articles on the subject.
Stercoral colitis: diagnostic value of CT findings. Diagn Interv Radiol. 2017 Jan; 23(1): 5–9.
Published online 2016 Dec 2. doi: 10.5152/dir.2016.16002
Abstract
Stercoral ulcer perforation is a life-threatening surgical condition which is thought to result from necrosis of the bowel wall due to an ischemic pressure by stool. This condition usually afflicts patients with chronic constipation. CT scan can identify most of the cases and emergent surgery is usually indicated.
Keywords: Stercoral ulcer, Perforation, Chemotherapy
Stercoral Ulcer-Associated Perforation and Chemotherapy. Case Rep Oncol. 2017 May-Aug; 10(2): 442–446.
Published online 2017 May 16. doi: 10.1159/000475756
Abstract
PURPOSE
We aimed to evaluate the CT findings of stercoral colitis (SC).
METHODS
Forty-one patients diagnosed with SC between February 2006 and April 2015 were retrospectively reviewed.
RESULTS
Rectosigmoid colon was the most frequently involved segment (100%, n=41). CT findings can be summarized as follows: dilatation >6 cm and wall thickening >3 mm of the affected colon segment (100%, n=41), pericolonic fat stranding (100%, n=41), mucosal discontinuity (14.6 %, n=6), presence of free air (14.6%, n=6), free fluid (9.7%, n=4), and pericolonic abscess (2.4%, n=1). The sign most related with mortality was the length of the affected colon segment >40 cm.
CONCLUSION
CT has an important role in SC, since life-threatening complications can be easily revealed by this imaging modality. Increased length of involved colon segment (>40 cm) is more likely to be associated with mortality.
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Charles A. Pilcher MD FACEP
Editor
All that follows is from Patient dies of perforated colon ulcer due to stercoral colitis (SC)
Good documentation prevents lawsuit in this case of a rare condition
Facts: A 56 yo female is brought to the ED by her husband for “shaking” at home and being weak “like a ragdoll.” He thinks this is due to the chronically high doses of opioids she has been taking for chronic back pain. He adds that she has had poor PO intake and a 20# weight loss in the past month, but the patient herself is not concerned. ROS is positive for constipation for several days, a subjective fever at home and mild pain in the chest, back and abdomen. She is afebrile in the ED. Exam reveals an alert female with abdominal distention and slight tenderness without rebound. An abdominal x-ray confirms a large amount of stool in the large intestine. Drug levels for both hydrocodone and hydromorphone indicate that she has been taking as much as 10X the therapeutic dose of both drugs. A CBC is remarkable for a WBC of 11,500 with 31% bands. She improves considerably with IV fluids and is diagnosed with “constipation,” “failure to thrive” and “dehydration.” She is advised to take a laxative, drink fluids and decrease her use of opioids. She wants to go home and her family concurs that she will be safe. She is to f/u with her PCP in the next 1-4 days. An extensive MDM indicates an extensive discussion with the family about her abdominal pain and the discharge plan. Three days later she is admitted to a second hospital with a bowel perforation and sepsis. Surgery finds stercoral colitis (SC) and a large perforated “stercoral ulcer” of the proximal sigmoid colon with disseminated pus. She expires 10 days later. The family consults an attorney. The attorney sends the records to an EM expert to assess the viability of the case.
Plaintiff: You should have discovered how sick I was on my first ED visit. My band count was sky high because I had a major infection. You should never have let me go home. High dose opioid use is associated with constipation, and prolonged constipation causes stercoral ulcers, and stercoral ulcers often perforate. You should have known that.
Defense: You had no fever. Your x-ray showed only the expected constipation with no free air. Your abdomen was only slightly tender and you weren’t even complaining about it. I was aware of your bandemia but just failed to mention it in my notes. You and your family should never have insisted on going home. I extensively discussed the risks and benefits of this plan with you and your family and documented it in your record. You also can’t prove that you had the perforated ulcer on the first ED visit. And stercoral ulcers are rare.
Result: For debatable reasons, the family’s attorney decided not to pursue a lawsuit. First, for whatever reason, he was uncomfortable with the family of the deceased. Second, the family of the deceased seemed to lose interest in pursuing the case. Third, despite not mentioning the bandemia in his notes, the EP’s chart was otherwise exceptionally well-documented including bowel perforation and other serious abdominal pathology in his differential. He also documented detailed discussions with the patient and her family about the causes of her pain and her opioid use. The family and the patient all preferred that she go home and follow up with her PCP.
Takeaways:
* While the result seems unexpected, the case has important teaching points.
* Not addressing the sledgehammer of a 31% bandemia is a major lapse. Overlooking bandemia happens all too often in med mal lawsuits for sepsis, necrotizing fasciitis, perforated appendix, etc. Never send home a patient with significant bandemia, especially 31% bandemia. If you ever do, your MDM should clearly explain why.
* A “stercoral ulcer” is an ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation due to a large bowel obstruction. It is most commonly located in the rectum.
* SC of the colon should be considered in all opioid-dependent patients with abdominal pain and chronic constipation. Resultant ulcers often perforate with disastrous results.
* The average age of patients with stercoral colitis is 76.
* It is rare and first reported in 1896. (1) A recent review {2) of over 800,000 ED visits found only 269 cases where this was considered – and 31% of those patients were discharged home.References:
1. Stercoral ulcer. Mumford JG. Boston Medical and Surgical Journal, Volume CXXXVI, No. 6, December 1, 1896.
2. Stercoral Colitis in the Emergency Department: A Retrospective Review of Presentation, Management, and Outcomes. Keim AA. Ann Emerg Med, March 23, 2023.
3. A systematic review of stercoral perforation. Chakravartty S et al. Colorectal Disease, 19 January 2013
