Schlüsselwörter Riesen-Kolonfäkalit - endoskopische Fenestration - Katheterisierung
Keywords giant colonic fecalith - endoscopic fenestration - catheterization
Introduction
Fecalith obstruction of the colon is not rare, and successful endoscopic treatments
can avoid surgical intervention. However, endoscopic attempts at removal of the fecalith
are often unsuccessful because of its size and its extremely hard stone-like consistency
[1 ]. We herein report the case of a new technique of endoscopic treatment using a snare
to fenestrate the fecalith and allow placement of a transrectal gastric tube for directed
instillation of the enema fluid.
Case Report
A 41-year-old woman was admitted presenting with abdominal pain and vomiting without
defecation or flatus for over two weeks. She had a surgical history remarkable for
a cesarean section and subsequent surgery for lysis of adhesions. The bowel sound
counts were seven counts per minute. There was left lower-quadrant tenderness to palpation
but no rebound pain or muscle tension. An abdominal CT scan showed a large amount
of fecal material in the descending and sigmoid colon with obvious dilation of the
proximal colon ([Fig. 1 ] (1)). The gastric tube aspirate only resulted in a small amount of clear gastric
fluid after three days and was subsequently removed because of the patient’s intolerance.
Enemas using 800 mL of warm water were performed three times/day but resulted in only
a small amount of fecal residues. Five days after admission, a colonoscopy was performed,
which showed that the colon was tortuous and an immovable giant fecalith blocked the
cavity of the sigmoid colon ([Fig. 1 ] (2)). Endoscopic removal was attempted using a snare. However, there was little
space for snare placement between the giant fecalith and the colonic wall. The fecalith
was so hard that the snare became deformed in shape and, after repeated attempts,
only a very limited amount of fecal material was able to be removed. The endoscopic
visualization was hampered by the accumulation of fecal material. The procedure was
aborted after about two hours. A subsequent enema yielded only a small amount of fecal
material, so a repeat endoscopic treatment was performed three days later. Given that
the snare was unsuccessfully used to trap the fecalith on the first attempt, we modified
the technique. The steel wire of the snare was retracted into the sheath, and the
sheath tube itself was used to fenestrate the fecalith longitudinally in the middle
line of fecalith. We then deployed the snare from the fecalith using the previously
created fenestration tract ([Fig. 1 ] (3)). After repeating the sequence of fenestration, snare insertion, and removal
of fecal material, a significantly larger amount of fecal material was extracted compared
to the previous attempt ([Fig. 1 ] (4)). However, the residual fecalith was still unable to be moved. We then passed
a gastric tube inserted just beside the fenestration, whose head was fixed by a No.
0 surgical suture and two clips ([Fig. 1 ] (5)). The second procedure took two hours. The gastric tube placed during the colonoscopy
was then used for instillation of fluid for an enema treatment. However, the gastric
tube fell out one day later. It was replaced during a third colonoscopy procedure
and secured using a single clip and a No. 4 surgical suture ([Fig. 1 ] (6)). After the re-insertion of the gastric tube, it was used for instillation of
200 mL warm water as an enema three times/day. A large amount of fecal material was
evacuated over the following five days. The patient’s symptoms improved, and the distention
of the colon was alleviated. As the abdominal distension and pain were relieved, the
patient was instructed to be given 20 mL of sesame oil orally, three times per day.
Seven days after the second catheterization, the gastric tube fell out once again.
A colonoscopy was performed and successfully reached the terminal ileum, and no tumor
or residual fecalith was found. The patient had an uneventful subsequent recovery
with no further episodes of bowel obstruction.
Fig. 1 The process of treatment for a giant colonic fecalith causing bowel obstruction. (1 ) Abdominal CT scan showed a large amount of fecal residues in the descending and
sigmoid colon with obvious dilation of the proximal colon; (2 ) An immovable giant fecalith blocked the sigmoid colon cavity; (3 ) Fenestration of the center of the fecalith; (4 ) After fenestration, a snare was used for attempt extraction of the fecalith; (5 ) A gastric tube was inserted and fixed by surgical suture and clips; (6 ) After the second colonoscopy, the abdominal CT scan showed that the gastric tube
was located below the fecalith.
Discussion
Obstruction of the colon caused by a fecalith is not a rare condition, but endoscopic
attempts at removal of the fecalith are often unsuccessful because of the size of
the fecalith and its extremely hard stone-like consistency. In recent years, an increasing
number of endoscopic treatments using techniques such as lithocrush baskets, intracorporeal
pneumatic/ultrasound lithotripters, and electrohydraulic lithotripsy have been reported
[2 ]
[3 ]
[4 ]. Some hospitals do not have access to these techniques. The dilation of the colon
that is caused by bowel obstruction makes it difficult to perform laparoscopic surgery,
which is a minimally invasive surgical method. Furthermore, when the fecalith is located
in the sigmoid colon, it may be difficult to perform a surgical anastomosis because
of the higher risk of subsequent fistula formation. Successful endoscopic treatments
can avoid surgical intervention, so we report the case of a new technique of endoscopic
treatment using a snare to fenestrate the fecalith and allow placement of a gastric
tube with several advantages. Endoscopic fenestration using a snare can be an effective
treatment when initial extraction attempts using the snare fail. We recommend attempting
to extract as much fecalith as possible, using the snare to morselize the fecalith
if necessary. This should be accompanied with the use of enemas to further soften
the fecalith. Secondly, the falling off of the gastric tube is related to the extremely
thick fixed suture that affects the force of the clip on the tissue. Therefore, it
is recommended that securing the gastric tube be performed with a thinner suture,
or dental floss, compared to a thicker suture. With fenestration and catheterization,
the enema liquid can reach and further penetrate into the fecalith more successfully.
This is more efficacious and requires a smaller volume of fluid than a conventional
enema (200 mL vs. 800 mL), which is more comfortable for the patient and more convenient
for the staff. It is important to note that endoscopic treatment is only appropriate
in cases without acute complete bowel obstruction or peritonitis. Because the overall
treatment process has a relatively long duration, it is necessary to carefully monitor
the patient’s condition and rapidly respond to changes that may necessitate urgent
surgical intervention.
