A Giant Abdominal Mass: Fecaloma

Abstract

A 67-year-old man was admitted to our hospital for 2-month constipation, nausea, and abdominal pain. Abdominal distention had been added to his list of complaints for about 2 weeks. He was not able to pass stool but did have discharge of gas. The patient had no history of serious illness, hospitalization, or major surgery, but he had been smoking cigarettes and cannabis and using various kinds of laxatives for many years. On initial evaluation, he had a temperature of 37.8°C, a heart rate of 106 beats per minute, respiratory rate of 16 breaths per minute, and blood pressure of 95/60 mm Hg. He was found to be in an agitated condition; on physical examination, his skin was wet and the patient seemed anxious. Bowel sounds were hypoactive, especially in the left quadrant. Palpation revealed a hard, nonmobile, tender abdominal mass filling the mid and left abdominal quadrants (Figure A). Digital rectal examination revealed hard stool impaction. Blood tests revealed: hemoglobin, 15 g/dL; hematocrit, 42; white blood cells, 16.800/mL; sedimentation rate, 61 mm per hour; blood glucose, 148 mg/dL; urea, 58; creatinine, 0.6; Na, 135; protein, 5.5; and albumin, 3.1 g/dL. Carcino-embryonic antigen, CA 19–9, and alpha-fetoprotein levels were normal. Abdominal tomography showed a giant fecaloma in the pelvis and left side of the abdomen causing displacement of visceral structures to the right side (Figure B; b, bladder; f, fecaloma). A hard mass of feces that could not be fragmented was noted on sigmoidoscopic examination. Repeated enemas and laxatives were used to stimulate defecation, but they were all unsuccessful. It was decided that the patient required abdominal surgery. Laparotomy was performed with a midline incision. During the exploration, we discovered that the descending and sigmoid colons were filled with a giant fecaloma. To extract the colon from the abdomen, a midline incision was made, extending from the xiphoid process to the level of the pubic symphysis. The diameter of the sigmoid colon was approximately 20 cm (Figure C). Resection of the descending and sigmoid colons, manual extraction of the remainder of the fecalomas from the rectum, and terminal colostomy were performed following Hartmann's technique (Figure D). The histopathologic study revealed atrophy of the mucosa and submucosa (Figure E), and pigmented macrophages in the lamina propria (melanosis coli) (Figure F). These histopathologic results were compatible with idiopathic megarectum and megacolon. Fecal impaction is a common and disturbing problem. Fecalomas occur most frequently in the distal colon and rectum and commonly give rise to obstruction. It can cause some serious complications such as colonic obstruction and perforation, sciatica, ureter obstruction secondary hydronephrosis, and deep vein thrombosis.1Nguyen H. Simpson R.R. Kennedy M.L. et al.Idiopathic megacolon causing iliac vein occlusion and hydronephrosis.Aust N Z J Surg. 2000; 70: 539-542Crossref PubMed Scopus (9) Google Scholar, 2Alvarez C. Hernández M.A. Quintano A. Clinical challenges and images in GI: Image 2: Deep venous thrombosis due to idiopathic megarectum and giant fecaloma.Gastroenterology. 2006; 131 (983): 702-703Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Without an organic cause, and if accompanied by a progressive expansion, this condition is called idiopathic megacolon.3Gladman M.A. Dvorkin L.S. Scott S.M. et al.A novel technique to identify patients with megarectum.Dis Colon Rectum. 2007; 50: 621-629Crossref PubMed Scopus (19) Google Scholar Rectosigmoidoscopy, barium enema, and abdominal tomography scan play important roles in differential diagnosis. Commonly, fecalomas can be treated by conservative methods such as laxatives, enemas, and digital evacuation. However, sometimes, as in this case, surgical intervention may be required for removal of the fecaloma.4Gladman M.A. Scott S.M. Lunniss P.J. et al.Systematic review of surgical options for idiopathic megarectum and megacolon.Ann Surg. 2005; 241: 562-574Crossref PubMed Scopus (85) Google Scholar, 5Rajagopal A. Martin J. Giant fecaloma with idiopathic sigmoid megacolon: report of a case and review of the literature.Dis Colon Rectum. 2002; 45: 833-835Crossref PubMed Scopus (29) Google Scholar Melanosis coli is characterized by pigmented macrophages in the mucosa and is a common side effect of prolonged laxative use.6Villanacci V. Bassotti G. Cathomas G. et al.Is pseudomelanosis coli a marker of colonic neuropathy in severely constipated patients?.Histopathology. 2006; 49: 132-137Crossref PubMed Scopus (20) Google Scholar