Stercoral Perforation in a Patient on Suboxone Treatment

Abstract

Background Opioids are a common cause of constipation, which can lead to fecal impaction, colonic ulceration, necrosis, and perforation. Although uncommon, stercoral perforation is a serious complication and carries high rates of morbidity and mortality. Prompt surgical intervention is essential to optimize outcomes. Case Presentation We present a 33-year-old Caucasian female who was transferred for management of nausea, vomiting, and abdominal pain. She had a history of multiple abdominal surgeries and began using prescription opioids for pain management 10 years ago and began using IV heroin 7 years ago. She had recently completed several weeks of methadone inpatient rehabilitation and was in remission with suboxone therapy. On exam, she had tachycardia and significant abdominal tenderness. She had leukocytosis. The patient received medical management for ileus, abdominal pain, and anxiety with tap water enema, IV fluids, cefepime, metronidazole, lorazepam, phytonadione, acetaminophen, pantoprazole, ondansetron, quetiapine, calcium gluconate, and suboxone. A CT scan indicated perforation in the distal sigmoid colon with feculent peritonitis, and the patient was taken to the operating room for emergency laparotomy and required a total colectomy and end ileostomy. She was stabilized and discharged home and returned several weeks later for intraperitoneal drain placement. She did not have further associated complications. Conclusion Stercoral perforation is a rare but serious complication of chronic constipation. Patients with long-term opioid use have an increased risk for stercoral perforation, and there should be a low threshold for imaging and prompt intervention to avoid this life-threatening complication.