Gastroenterology
Volume 139, Issue 3 , Pages e10-e11, September 2010

Vomiting and Painful Abdomen in Dementia

  • Alexey Surov, MD

      Affiliations

    • Department of Radiology, Martin-Luther-University, Halle-Wittenberg, Germany
    • ,
  • Frank Mannes, MD

      Affiliations

    • Department of Surgery, Martin-Luther-University, Halle-Wittenberg, Germany
    • ,
  • Curd Behrmann, MD

      Affiliations

    • Department of Radiology, Martin-Luther-University, Halle-Wittenberg, Germany

published online 06 August 2010.

Article Outline

 

Question: A 47-year-old man with a known history of dementia was admitted to our emergency department because of nausea and vomiting. Communication with the patient was impossible owing to his mental status. According to the nursing personnel, there was no history of trauma, and the patient did not receive any drugs.

On physical examination the abdomen was diffusely painful. There were no signs of peritonism. Laboratory investigations revealed a hemoglobin concentration of 9.3 g/dL. White cell count and blood chemistry tests were normal. Computed tomography (CT) of the abdomen is shown (Figure A). What is the diagnosis?

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Answer to the Clinical Challenges and Images in GI Question: Image 5: Massive Fecal Impaction Complicated by Stercoral Colitis 

Abdominal CT showed a massive fecal impaction (FI) of the elongated and dilated rectosigmoid colon (Figure A). Furthermore, CT demonstrated a wall thickening with contrast enhancement of the rectosigmoid colon. Rectal examination confirmed hard fecal masses and blood. In view of the radiologic findings a secondary ischemia of the rectosigmoid colon was suspected.

The patient underwent a resection of the dilated sigmoid (Figure B). Histopathologic examination revealed a stercoral colitis with typical ulcerations secondary to FI. There was no malignancy. The postoperative course was uneventful and the patient was discharged from our clinic in good general condition.

It is well known that constipation and FI can occur in the elderly.1 Dehydration, reduced physical activity, and stiffness of pelvic and abdominal muscles play a key role.1 Furthermore, FI in the rectosigmoid is not an uncommon complication of tumors, Hirschsprung disease, or colonic diverticula.2, 3 FI is associated with several neurologic diseases, such as multiple sclerosis, spinal cord injury, poliomyelitis, Parkinson disease, diabetic autonomic neuropathy, and dementia.2 Furthermore, FI has been described in association with several drugs, such as codeine, calcium channel blockers, aluminium-based antacids, nonsteroidal anti-inflammatory drugs, and immunosuppressive agents.1, 3 It can also occur during therapy with opiates, antidepressants, or antipsychotic drugs.2

In this case, because no organic cause was found, the massive FI was presumably related to the patient's dementia and diet.

Massive fecal masses increase intramural bowel pressure and can consequently cause bowel ischemia, focal inflammation with ulceration or stercoral colitis, perforation, and stercoral peritonitis.2, 3 The exact incidence of these complications secondary to FI is unknown. According to the literature, the incidence of stercoral peritonitis varies here from 1.2% to 4.6%.3 Other complications secondary to the FI, such as respiratory arrest, obstructive hydronephrosis, and acute lower limb ischemia have been also described in the literature.1, 2, 3 Therefore, massive FI should be treated promptly. In our patient, a massive FI was complicated by stercoral colitis.

FI may be misdiagnosed in psychiatric patients owing to impairment of proper communication, as in the presented case. Fecal masses without other complications can be disimpacted manually.1 Complicated cases, as presented herein, should be treated operatively.1, 2, 3

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References 

  1. De Lillo AR, Rose S. Functional bowel disorders in the geriatric patient: constipation, fecal impaction, and fecal incontinence. Am J Gastroenterol. 2000;4:901–905
  2. Johanson J, Sonnenberg A, Koch T, et al. Association of constipation with neurologic disease. Dig Dis Sci. 1992;37:179–186
  3. Heffernan C, Pachter HL, Macari M. Stercoral colitis leading to fatal peritonitis: CT findings. AJR. 2005;184:1189–1193

 Conflicts of interest The authors disclose no conflicts.

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PII: S0016-5085(10)00100-9

doi:10.1053/j.gastro.2009.10.067

Gastroenterology
Volume 139, Issue 3 , Pages e10-e11, September 2010

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