EP604 - Primary Anastomosis and Diverting Loop Ileostomy (PADLI) for Perforated Stercoral Colitis: A Case Report

Purpose/Background: Stercoral colitis is an inflammatory condition of the bowel wall. It is caused by large stool burden and is associated with high intraluminal pressures in the rectosigmoid junction and/or distal colon due to the presence of large volumes of impacted stool. It can lead to bowel ulceration, ischemia, perforation, sepsis and death. The incidence of stercoral perforation is low, accounting for 3.2% of colonic perforations requiring surgical intervention. The etiology of ulceration is thought to be due to ischemia from pressure of the stool ball on the bowel wall. These patients are at risk of sepsis and even death. Often, surgical management is needed. The surgical management depends on the location of the perforation. Primary anastomosis and diverting loop ileostomy (PADLI) is primarily associated with perforated diverticulitis. There have been multiple studies that have looked at the results between Hartmann's procedure and primary anastomosis for perforated diverticulitis, favoring primary anastomosis. Following this, there have been studies about diverting a primary anastomosis with a loop ileostomy vs not, and the results of those studies have been inconclusive. The rate of ostomy reversal, however, is significantly higher in those with a PADLI. There has been a paucity in the literature about the preferred method of operation for perforated stercoral colitis and feculent peritonitis. This case is meant to address the role of PADLI for perforated stercoral colitis.

Methods/Interventions: This was a case report.

Results/Outcomes: Our patient was a 73-year-old female who presented to the emergency department with complaints of abdominal pain, nausea, and vomiting. Her medical history was notable for constipation, colitis, asthma, GERD, and hyperlipidemia. In the emergency department she was found to have a leukocytosis of 17, lactic acidosis of 4.9, and creatinine of 1.17. She was initially hypotensive with a systolic in the high 90s with no associated tachycardia but with tachypnea into the 30s. CT imaging showed a focal segment of mural thickening and hypoenhancement of the sigmoid colon suggestive of ischemia. She then progressed to instability with systolic blood pressures in the 50s and increasing oxygen requirements. She was taken to the OR emergently and was found to have a perforation in her sigmoid colon, feculent peritonitis, and an abscess around her small bowel. The portion of her sigmoid was resected, and irrigation was performed. She was on two pressors and her abdomen was left open. The next day her pressor requirements were lessening, and she was taken back to the OR, where it was noted that the blind ends of colon were healthy appearing and her small bowel was without injury. A primary anastomosis of the colon and a diverting loop ileostomy were created, and the abdomen was closed. She was transferred back to the ICU post operatively. Her hospital course was complicated by surgical site infection to her midline wound requiring removal of staples and VAC placement. Otherwise, she regained bowel function, tolerated a diet, and went home with home health care and physical therapy. She followed up in the office and received a colonoscopy in preparation for ostomy reversal. She returned for reversal of her ileostomy and was discharged from the hospital a few days after.

Conclusion/Discussion: Further research needs to be undertaken in this area of study; however, it appears as though in a patient with perforated stercoral colitis and feculent peritonitis, a PADLI is a viable option to avoid the morbidity of a Hartmann's type procedure