Stercoral Ulcer and Colonic Perforation in an Individual with Parkinson's Disease with Constipation.

Abstract

To the Editor: Stercoral ulcer and colonic perforation are gastrointestinal emergencies because peritonitis inevitably ensues.1-3 We recently had a case of stercoral ulcer and colonic perforation in an elderly woman with Parkinson's disease (PD) who had long had constipation. A 75-year-old woman with a 15-year history of PD (Hoehn-Yahr motor grade 3, independent walk, right hand tremor at rest, mild rigidity, akinesia)4 had mild overactive bladder and mild postural dizziness but no apparent rapid eye movement sleep behavioral disorder and no depression or apparent cognitive disorder. She had been taking 400 mg/d of levodopa with 30 mg/d of carbidopa, 2.0 mg/d of cabergoline, and 5 mg/d of selegiline. She had not undergone a dopamine transporter scan or metaiodobenzylguanidine myocardial scintigraphy, but neurological examination and magnetic resonance imaging showed no evidence of white matter ischemia, orthopedic illness, multiple system atrophy, progressive supranuclear palsy, or other causes of degenerative parkinsonism. She had mild diabetes mellitus (glycosylated hemoglobin 7.2%, normal <6.0%) but had no numbness in the hands or feet and preserved deep tendon reflexes; nerve conduction study results were normal. She had a long history of constipation (low frequency of bowel movements (once per 2–4 days), difficulty defecating), for which she took occasional laxatives from a local clinic. She developed abdominal pain and mild fever with the constipation, which did not respond to laxatives and other medication from the clinic. These symptoms brought her to the emergency department at our hospital. On admission, she was alert, with a mild fever (37.6°C). Neurological findings were unchanged (Hoehn-Yahr motor grade 3), but her abdomen was distended, with tenderness and defense at the lower part and decreased abdominal sounds. Laboratory examination showed high C-reactive protein (20.55 mg/dL, normal <0.1 mg/dL) and a white blood cell count of 14,700/μL (normal <8,000/μL). Other blood test and urinalysis results were normal, except for mildly high blood urea nitrogen (21.0 mg/mL, normal <15 mg/mL). Plain abdominal X-ray in the lying posture showed abdominal distension, gas, and fecal impaction in the small intestine and colon (Figure 1A). Abdominal computed tomography revealed fecal impaction in the colon and rectum and ascites and extraluminal bubbles of gas (free air) in the abdomen (Figure 1B).1, 2 These clinical and laboratory features strongly indicated perforation in the lower gastrointestinal tract, and she underwent emergency surgery. She was found to have severe distension of the sigmoid colon, with three orifices of perforation, mucosal erosion, and fecal impaction throughout the transverse colon, descending colon, sigmoid colon, and rectum. She had no carcinoma. A stoma was place in the left lower abdomen, and she was started on 15 g/d of oral Dai-kenchu-tou, an herbal medicine that facilitates colonic transit through serotonin 5HT3 receptors.5 Her gastrointestinal symptoms improved and remained unchanged for the following 12 months. Stercoral (stool, fecal) ulcer is a rare gastrointestinal and surgical emergency,1-3 first reported in 1894;6 35% mortality has been reported. It is considered a pressure ulcer in the colon or rectum caused by obstruction (impaction), high intraluminal pressure, and focal ischemia, all from the conglomerated, dehydrated stool in situ. This condition is reported to occur in elderly adults with chronic constipation (particularly nursing home residents), neurologically impaired individuals (details not available), and in individuals taking certain medications (opiates, tricyclic antidepressants, tranquilizers), al of which can slow colonic transit.7 If not treated, ulceration leads to perforation, which appears at the sigmoid colon in 77% and is in multiple places in 27% of cases.1-3, 6 Stercoral ulcer and colonic perforation have not been recognized in individuals with PD, although constipation, slow colonic transit, and anorectal abnormality are common in individuals PD, primarily due to neuronal loss and Lewy bodies in the myenteric plexus, which may occur earlier than motor disorder in PD.7, 8 In PD, not only constipation, but also delayed gastric emptying, poor levodopa absorption, intestinal pseudoobstruction, and the malignant syndrome can ensue after gastrointestinal autonomic disorder.9, 10 Of these, stercoral ulcer and colonic perforation are a life-threatening complication. To prevent this condition, neurologists should treat constipation in individuals with PD, particularly those who are elderly. Conflict of Interest: None of the authors have conflict of interest. Author Contributions: Tateno, Tsuyusaki, Kishi, Tateno, Ogata: acquisition of subjects and data. Sakakibara: study concept and design, acquisition of subjects and data, analysis and interpretation of data, preparation of manuscript. Aiba: acquisition, analysis, and interpretation of data. Sponsor's Role: None.