Megabowel and Giant Fecaloma: a Surgical Condition?

Excerpt

A 79-year-old patient presented to the emergency room for progressive abdominal distension and shortness of breath. He had no significant past medical history except for chronic constipation for which he was not compliant with his medication. He had not had a bowel movement over the preceding 2 months. His vitals were normal but he displayed a restrictive respiratory pattern. Upon physical examination, we found a non-tender but severely distended abdomen, considerable fecal impaction, and signs of bilateral peripheral edema. At this point, we suspected a giant fecaloma with megabowel. This was confirmed by an abdominal series, which showed severe sigmoid distension with fecal residue. A computed tomography was performed and revealed a megasigmoid with fecal impaction reaching the right hypochondriac region (Fig 1). The sigmoid loop measured 22 cm at its largest diameter. The liver and remaining viscera were upwardly displaced (Fig. 2). There was compression of the iliac venous system and the left pelvic ureter with hydronephrosis. There were no signs of bowel pneumatosis, volvulus, or parietal thickening. Laboratory tests also confirmed the compressive nature of the fecal impaction with mild leukocytosis, cholestasis, lactic acidosis, and acute kidney failure. Volume resuscitation was initiated and a surgical approach was discussed with the patient from the start. The decision of an initial surgical treatment was based on the patient age, history of chronic constipation, megabowel, and significant fecal impaction with venous and ureteral compression. With his consent, a Hartmann procedure was performed not without challenge. The distended sigmoid loop was casted in the right diaphragm with the liver lifted anteriorly making its extraction difficult despite a median xyphopubic incision. A sigmoid colotomy was performed in order to evacuate gas and manually extract feces without spillage. An 8-cm wide megarectum tenia was measured at the sacrum level (Fig. 3). It was stapled after dissecting away the left ureter. A terminal colostomy was easily performed given the normal width of the left colon. Postoperative care was uneventful with return to normal transit, recovery of renal function, regression of hydronephrosis, and relief of peripheral edema. The patient subsequently reported a good quality of life. The pathology report confirmed an idiopathic megacolon. The institutional board approved this article in accordance with ethical standards and 1964 declaration of Helsinki.

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