Neuroleptiques Causing a Giant Abdominal Mass

Abstract

A 39 years old patient was admitted to our hospital, never operated before, with a history of mental illness. The patient was treated for schyzophrenia since the age of 15, under a long term treatment of neurolyptics and antidepressants, with complaints of chronic constipation. The patient reported abdominal pains and cessation of stool and gas, no defectation in 15 days, along with continuous vomitting.The patient was concious, instable TA : 80/40mmHG FC: 120B/m FR : 22 c/m. On initial evaluation we could detect an important abdominal distention as well as an apparent venous collateral circulation accompagnied with tenderness to palpation [Figure A]. Rectal examination revealed the presence of a very hard fecaloma. The initial biological assessment showed functional renal insufficiency, Hyperleukocytosis at 11000 /mm3, hyponatremia at 125 mmol/L. Abdominal tomography revealed a giant fecaloma at the rectum, the sigmoid and the left side of the transverse colon, and a mega colon with a diametre reaching 22 cm wide, the lining of the colon was improperly enhanced after the injection of the contrast agent [Figure B]. The patient was then admitted to the trauma room, he was prepared with a rehydration and hydro-electrolytic compensation. Repeated enemas and laxatives were used to stimulate defectation, but they were all unsuccessful, the hard mass of stool could not be removed. It was decided that the patient required abdominal surgery. Under general anesthesia, patient in supine position, a midline laparotomy was performed. During the exploration, we discovered a colon filled with a giant ficaloma, along with ischemic parietal lesions on the sigmoid [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. The patient remained instable even after being treated in intensive care, the patient unfortunately passed away 48 h post operation.
 Constipation is a common problem that can cause fecal impaction and even development of a fecaloma, a mass of inspissated stool. Fecalomas occur more frequently in the left colon and rectum as stool hardens and the colon narrows. Fecalomas can manifest in various ways including bowel obstruction, urinary retention, and toxic megacolon.
 Medica­tions that were significantly associated with constipation were opioids, diuretics, antidepressants, antihistamines, antispasmod­ics, anticonvulsants, and aluminum antacids. The use of acetaminophen (>7 tablets weekly), aspirin, and other NSAIDs was also found to be associated with an increased risk of constipation. Fecalomas can often be treated conservatively with laxatives, enemas, and/or digital disimpaction. However, when these methods are unsuccessful, surgical intervention is required to prevent bowel perforation.
 In patients with history of constipation, new or worsening of abdominal pain, and are under antidepressants and neurolyptic treatment, fecalomas should be considered in the differential diagnosis, and constipation should be aggressively investigated to avoid complications.