Sigmoid colon perforation presumed to be stercoral in origin in an elderly patient with chronic constipation: a case...

Stercoral perforation (SP) is an uncommon but potentially life-threatening complication of chronic constipation that predominantly affects elderly individuals. Early diagnosis is challenging because of nonspecific clinical manifestations and the risk of rapid progression to feculent peritonitis and sepsis. We report the case of an 85-year-old woman who presented with severe acute lower abdominal pain, abdominal distension, nausea, vomiting, and absence of flatus or bowel movements. She had a 6-month history of chronic constipation and long-term antihypertensive therapy with levamlodipine besylate. Computed tomography (CT) demonstrated free intraperitoneal air, abdominal fluid, and fecal impaction within the sigmoid colon. Emergency laparoscopic exploration followed by limited open surgery revealed severe feculent peritonitis and a 2.5 cm × 2.0 cm perforation of the distal sigmoid colon. Necrotic tissue at the perforation margin was debrided, and the perforated sigmoid segment was exteriorized and matured as a colostomy. No bowel resection was performed because diffuse ischemia or necrosis was not identified intraoperatively and the patient was considered high risk because of advanced age and poor baseline condition. The diagnosis of probable stercoral perforation was based on the clinical presentation, radiological findings, and intraoperative observations. Postoperatively, the patient required intensive care monitoring and received broad-spectrum antimicrobial therapy, nutritional support, and electrolyte replacement. She was discharged in stable condition on postoperative day 14. At the 11-week follow-up, she tolerated a regular diet and reported regular bowel movements. At 1-year follow-up, she remained independent in daily activities, with no recurrent perforation, severe constipation, or rehospitalization. This case highlights the importance of early CT evaluation, individualized surgical decision-making, prompt source control, and comprehensive perioperative management in elderly patients with suspected stercoral perforation.