Large Bowel Obstruction With Cecal Perforation: What’s the Cause?
Stephen Winfield, MD; Claire Wunker, MS-IV; Sharon Sukhdeo, MS-IV; Jeremy Young, MS-IV; and Andrew Rosenthal, MD
Winfield S, Wunker C, Sukhdeo S, Young J, Rosenthal A. Large bowel obstruction with cecal perforation: What’s the cause? Consultant. 2016;56(10):942-945.
A 58-year-old man presented to the emergency department (ED) with a 1-month history of abdominal pain. He stated that the pain had acutely worsened and was constant, moderate, and sharp, with no alleviating or aggravating factors.
His last bowel movement had been 4 days ago, which he stated is normal for him, and he had passed flatus the day of presentation. He had never had a colonoscopy. He also reported decreased appetite, nausea, and constipation, but he denied weight gain, fever, vomiting, and diarrhea.
His past medical history included 3 cerebral vascular accidents (in 2008, 2009, and 2011), hypertension, hyperlipidemia, glaucoma, and traumatic left-eye blindness. His past surgical history was noncontributory. He had a positive family history for cancer (lung cancer in his father, who was a chronic smoker, and breast cancer in his mother). The patient smoked 1 pack of cigarettes per day, which had decreased from his previous smoking of 3 packs per day for 30 years. He also reported daily alcohol use, usually 5 to 6 12-oz cans of beer.
He had been prescribed cyclobenzaprine for muscle spasms after his most recent stroke, which had caused left-sided hemiparesis that had since resolved, as well as simvastatin for hyperlipidemia and aspirin for thromboembolic prophylaxis.
On physical examination in the ED, the man was noted to be alert and ill-appearing but in no acute distress. His temperature was 36.8°C, respiratory rate was 20 breaths/min, heart rate was 70 beats/min, and blood pressure was 130/94 mm Hg. His body mass index was 24.41 kg/m2. His abdomen was soft and distended, with no discoloration; it also was tympanic to percussion, with active bowel sounds and right-sided tenderness and guarding. The rectal vault was empty, with no blood or masses, and with normal rectal tone. His extremities exhibited no cyanosis or edema, and pulses were 2+ bilaterally. His skin was melanotic with poor turgor.
Initial laboratory test results showed a decreased potassium level (3.3 mEq/L) and an elevated alkaline phosphatase level (120 U/L). A computed tomography (CT) scan of the abdomen and pelvis (Figures) showed a constricting lesion at the junction of the descending colon and the sigmoid colon, with marked dilatation of the colon proximally. Additionally, cholelithiasis was evident. A flexible sigmoidoscopy was performed for further evaluation of the lesion and showed a sigmoid polyp and diverticulosis, in addition to the mass.
What is the most common cause of large bowel obstruction in the United States, including this patient's case?
B. Fecal impaction
C. Colorectal cancer
D. Acute colonic pseudo-obstruction
Answer and discussion on next page.