Medical Image of the Month: Stercoral Colitis

Figure 1. Non-contrast CT acquired at the time of admission demonstrating diffusely dilated large bowel loops from cecum to rectum measuring up to 8 cm. Image on the left (Panel A) shows a near-complete intrathoracic sliding-type herniation of stomach adjacent to a herniated portion of transverse colon through the diaphragm into the chest. The image on the right (Panel B) shows a markedly distended rectum with impacted stool with circumferential rectal wall thickening consistent with stercoral colitis. 

Figure 2. Non-contrast CT thorax demonstrating on the left (Panel A) large hiatal hernia with intrathoracic herniation of stomach and transverse colon. The image on the right (Panel B) shows mild mass effect upon the left atrium related to the herniated transverse colon.

A 78-year-old- man with cerebral palsy requiring an in-home caregiver presented to the emergency room in hypovolemic shock post-sudden cardiac arrest in the setting of hematemesis. The caregiver noticed the patient become unresponsive after having one episode of bright red emesis. EMS arrived and found the patient to be pulseless and performed three rounds of CPR and gave 1 mg of epinephrine before return of spontaneous circulation was obtained. The caregiver reported the patient had been complaining of diarrhea for the past few days after being started on magnesium citrate for constipation by his PCP. In the ED patient was intubated, sedated, and started on pressors due to undifferentiated shock. CT abdomen pelvis demonstrated diffuse dilation of the colon with massive stool burden and markedly distended rectum with impacted stool and circumferential rectal wall thickening consistent with stercoral colitis (Figures 1 and 2). In addition, there was a large hiatal hernia with intrathoracic herniation of the stomach and a portion of the transverse colon, but it did not appear to represent a point of high-grade obstruction. The patient was deemed a poor surgical or endoscopic candidate due to high perioperative mortality. Manual disimpaction was attempted with minimal stool output, mineral oil enemas were given, and OG tube decompression of stomach. The patient had a ST segment elevated myocardial infarction (STEMI) noted on EKG and despite pressors and aggressive IV fluid resuscitation patient’s condition continued to decline with family deciding to pursue comfort care. The patient’s profound constipation, large hiatal hernia, and stercoral colitis were contributing factors to his shock.

Stool impaction can occur secondary to chronic constipation as the colon absorbs salt and colitis is colonic perforation which has a mortality rate between 32-57 percent (1). The modality of choice for diagnosis is CT and the common findings are colonic wall thickening, pericolonic fat stranding, mucosal discontinuity, pericolonic abscess, and free air indicating perforation. A small retrospective study found that the most consistent findings in stercoral colitis were rectosigmoid colon involvement, dilation of the colon >6 cm, and bowel wall thickening >3 mm in the affected segment. It also suggests that colonic involvement of >40 cm and perforation indicate increased mortality (2,3). Stercoral colitis most commonly occurs in the elderly, those who are bedridden due to cerebrovascular events or severe dementia, chronic opioid use, malignancy, and those with motor disabilities, such as this patient with cerebral palsy.  In patients without signs of peritonitis or who are poor surgical candidates can be managed non-operatively with laxatives, enemas, and manual/endoscopic disimpaction (4). Early diagnosis and treatment are imperative to avoid perforation. Patients with signs of perforation require surgical treatment which involves resection of the affected bowel segments.

Kirstin H. Peters MSIV, Angela Gibbs MD, Janet Campion MD

University of Arizona School of Medicine, Banner University Medical Center-Tucson, Tucson, AZ USA

References

1. Serpell JW, Nicholls RJ. Stercoral perforation of the colon. Br J Surg. 1990 Dec;77(12):1325-9. [CrossRef] [PubMed]
2. Ünal E, Onur MR, Balcı S, Görmez A, Akpınar E, Böge M. Stercoral colitis: diagnostic value of CT findings. Diagn Interv Radiol. 2017 Jan-Feb;23(1):5-9. [CrossRef] [PubMed]
3. Wu CH, Wang LJ, Wong YC, et al. Necrotic stercoral colitis: importance of computed tomography findings. World J Gastroenterol. 2011 Jan 21;17(3):379-84. [CrossRef] [PubMed]
4. Hudson J, Malik A. A fatal faecaloma stercoral colitis: a rare complication of chronic constipation. BMJ Case Rep. 2015 Sep 3;2015:bcr2015211732. [CrossRef] [PubMed]

Cite as: Peters KH, Gibbs A, Campion J. Medical Image of the Month: Stercoral Colitis. Southwest J Pulm Crit Care. 2021;23(3):73-5. doi: https://doi.org/10.13175/swjpcc027-21 PDF 

Medical Image of the Month: Bleomycin-Induced Pulmonary Fibrosis in a Patient with Lymphoma

Figure 1. Representative images from the thoracic CT in lung windows showing scattered bilateral ground glass opacities with areas of fibrosis consistent with multifocal pneumonia superimposed on pulmonary fibrosis.

Figure 2. Representative image from the thoracic CT in lung windows done just prior to lung transplantation.

Abstract

Interstitial pulmonary fibrosis is the most feared complication of bleomycin therapy and occurs in up to ten percent of patients that receive the drug. The risk of bleomycin-induced pulmonary fibrosis is related to the age of the patient, the dose of medication given, the patient’s kidney function, and whether the patient smokes cigarettes. Current screening guidelines for bleomycin-induced lung injury are limited, but most clinicians screen high risk and symptomatic patients with pulmonary function testing. This case report is of a patient with lymphoma who received bleomycin as a part of his chemotherapy regimen, and later developed pulmonary fibrosis complicated by bouts of eosinophilic multifocal pneumonia. The case highlights the importance of close monitoring of patients taking bleomycin for signs and symptoms of pulmonary fibrosis and the need for major medical societies to issue concrete screening guidelines.

Introduction 

Bleomycin’s labeled indications include treatment of squamous cell carcinomas of the head and neck, Hodgkin lymphoma, non-Hodgkin lymphoma, malignant pleural effusions, and testicular cancer (1). The most feared complication of bleomycin is interstitial pulmonary fibrosis (2). Pathogenesis is not fully clear but involves oxidative damage secondary to reactive oxygen species (2). Risk factors include age > 40, renal insufficiency (CrCl < 80 mL/min), bleomycin dose > 300 units, and cigarette smoking (2). Symptoms present within one to six months of starting the medication and often begin with dyspnea and auscultatory crackles on physical exam (2). Associated signs and symptoms include cough, chest pain, opacities on chest radiographs, or an asymptomatic decline in diffusing capacity for carbon monoxide (2,3).

Screening for pulmonary fibrosis in patients taking bleomycin is controversial and no clear guidelines exist. Most physicians agree that it is appropriate to get baseline pulmonary function tests (PFTs) in patients receiving bleomycin, and thereafter screen with PFTs intermittently throughout the course of treatment (3). FDG-PET has also been used as a screening tool, but the evidence for its efficacy is mixed (4).

This is a case of a 56-year-old man with a presumed diagnosis of multifocal eosinophilic pneumonia superimposed on pulmonary fibrosis who had to be admitted to the ICU for respiratory distress. The patient recovered and underwent a lung transplant.

Case Presentation 

A 56-year-old man with a history of lymphoma diagnosed 11 years prior and treated with chemotherapy, including bleomycin, presented to the emergency department with fever, chills, and productive cough. A CT of the chest with IV contrast was performed which revealed scattered bilateral ground glass opacities with areas of fibrosis (Figure 1). Next, the patient underwent a bronchoalveolar lavage (BAL) and shortly thereafter developed respiratory distress with respiratory failure that required non-invasive ventilation and admission to the ICU. In the ICU, the patient responded to ceftriaxone, azithromycin, prednisone, and fluconazole. The bronchoalveolar lavage was significant for elevated levels of eosinophils and neutrophils. There were also possible fungal elements on touch prep but no fungal growth. The presumed diagnosis on admission was multifocal pneumonia superimposed on pulmonary fibrosis.  

After recovering, the patient was discharged. Four months later, he underwent a bilateral lung transplant. At explant, the final pathology report confirmed a mixed pattern of fibrosing interstitial lung disease, clinically due to bleomycin. Figure 2 shows the patient’s pulmonary fibrosis just prior to transplant.

The patient’s lung transplantation was successful, and he is currently doing well.

Discussion

Pulmonary fibrosis is a dangerous and relatively common complication of bleomycin. The differential diagnosis includes pulmonary infection, cardiogenic pulmonary edema, radiation-induced pulmonary fibrosis, metastatic disease, and adverse reaction to other medications. Presented here is a case where a patient received bleomycin as a part of his chemotherapy regimen for lymphoma, and subsequently developed pulmonary fibrosis. When the patient presented 11 years after his lymphoma diagnosis, he had eosinophilic multifocal pneumonia superimposed on his already existing pulmonary fibrosis.

This case illustrates the difficulty of managing the pulmonary manifestations of bleomycin in patients taking the drug. There are currently no screening guidelines in place for patients that take the medication (3). Shippee et al. suggest patients undergo PFTs at baseline before starting treatment, followed by PFTs every 3 weeks during therapy (3). They suggest bleomycin should be discontinued in patients who have a linear decline in DLCO of 40-60% from baseline (3).

It is unclear if our patient had been screened for pulmonary fibrosis while he was receiving bleomycin. Regardless, it would be prudent and appropriate for a major medical society to issue clear guidelines regarding screening for pulmonary fibrosis. Standardizing screening protocols will lead to better patient outcomes.

Martin A. Dufwenberg, BS  

University of Arizona College of Medicine – Tucson

Tucson, AZ, USA

Acknowledgments

The author thanks Dr. Michael Larson, M.D., Ph.D., for mentorship, discussion, and help in making this case report become reality.

References

1. U.S. Food and Drug Administration. Blenoxane (bleomycin sulfate for injection, USP). Updated April 2010. Accessed June 8, 2021. https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/050443s036lbl.pdf
2. Sleijfer S. Bleomycin-induced pneumonitis. Chest. 2001 Aug;120(2):617-24. [CrossRef] [PubMed]
3. Shippee BM, Bates JS, Richards KL. The role of screening and monitoring for bleomycin pulmonary toxicity. J Oncol Pharm Pract. 2016 Apr;22(2):308-12. [CrossRef] [PubMed]
4. Groves AM, Win T, Screaton NJ, Berovic M, Endozo R, Booth H, Kayani I, Menezes LJ, Dickson JC, Ell PJ. Idiopathic pulmonary fibrosis and diffuse parenchymal lung disease: implications from initial experience with 18F-FDG PET/CT. J Nucl Med. 2009 Apr;50(4):538-45. [CrossRef] [PubMed]

Cite as: Dufwenberg MA. Medical image of the month: bleomycin-induced pulmonary fibrosis in a patient with lymphoma. Southwest J Pulm Crit Care. 2021;23(2):49-51. doi: https://doi.org/10.13175/swjpcc024-21 PDF