S3391 Life-Threatening Complication of Chronic Constipation in a Young Patient

Abstract

INTRODUCTION: Bowel Perforation secondary to stool impaction is a rare entity which has amortality rate of 32-57%. It has Predilection to age 22-85. Risk factors include chronic constipation, NSAIDs, narcotics, antacids, steroids, antidepressants and antipsychotics. Stercoral perforation results from compression of colonic mucosaby a hard fecaloma causing mucosal ischaemia on antimesenteric border withulceration and perforation. CASE DESCRIPTION/METHODS: A 41Year Old Female with PMH of Bipolar disorder, Hypothyroid, HTN, substanceabuse, End Stage Kidney Disease presented with diffuse severe abdominal pain for 2 days. She had bowel enema done one day prior to her presentation. Pain was 10/10 intensity associated with nausea and dizziness. Vitals Pulse rate 115/min, Respiratory rate 22/min, Blood pressure 90/54mmHg, Temperature 98.5F. Her Home medications included Methadone, Quetiapine, Trazodone, Clonazepam, Docusate, Levothyroxine.On examination, abdomen was diffusely tender with signs of peritonitis. Labs WBC: 3.80, AST/ALT 1277/989, Alkaline phosphatase 380, Total bilirubin 2.0. Hepatitis panel negative. Abdominal CT showed chronic obstruction with bowelperforation of redundant sigmoid colon and massively dilated colon with full of stool. Pt was immediately taken to surgery after initial resuscitation and antibiotics. Pt had left Hemicolectomy with primary anastomosis and drain placedin the paracolic gutter. Intraoperatively she was found to have ruptured proximaldescending colon secondary to rock hard stools with generalized fecal peritonitis and pathology report showed colonic transmural Necrosis. She was transferred toICU due to septic shock from Enterococcus faecalis bacteremia started on Zyvox.Patient went into cardiac arrest. Despite aggressive management, unfortunately Pt did not survive. DISCUSSION: Due to widespread use of opioids, antidepressants and antipsychotics earlyrecognition and proper management of constipation is crucial to prevent mortality. Only 10% of individuals are correctly diagnosed and managed properly. Our Pt was taking antipsychotics, antidepressants in addition to Methadone. This resulted in constipation due to disturbances with the migrating myoelectriccomplex causing delay in fecal transit time. Avoiding enema in a Pt like this would be a crucial step as the mucosa is very fragile to cause perforation easily. Frequent monitoring and proper management of constipation could save many young lives.Figure 1Figure 2