Death Due to Perforation of Solitary Rectal Ulcer: Case Report

Overview

Presented case was 57-year-old male reported to be found dead in the watchman cabin in his workplace. At the autopsy, in abdominal cavity dirty green-brown colored fluid with a few particles of intestinal contents and yellow-green colored membranes on abdominal organs were observed, on the anterior wall of the rectum, 2x1.5 cm size perforation area was observed. We aimed to present the rare case of solitary rectal ulcer perforation.

Keywords:
solitary rectal ulcer – death – autopsy

Isolated colonic ulcers are rare lesions that are not associated with manifest colitis and usually can be determined by screening colonoscopy or abdominal pain, haematochezia, chronic gastrointestinal bleeding and sometimes perforation (1). While the most common cause of isolated colonic ulcers in the caecum and right colon is the use of non-steroidal anti-inflammatory drugs, ischemia, solitary rectal ulcer syndrome, stercoral ulcers and nonspecific idiopathic ulcers due to radiation and fecal impaction are among of the causes of isolated rectal ulcer (1,2). Although not as frequently as other reasons, solitary rectal ulcer cases induced connected to use of ergotamine are also defined in literature (3,4). Solitary rectal ulcer syndrome and stercoral ulcers are usually associated with local tissue ischemia and seen in elderly people (2). Although histopathological findings are characteristic, as because showing similarity in endoscopic appearance of inflammatory bowel diseases and malignant conditions and the clinical findings, may cause difficulties in the differential diagnosis (5,6). İn the case report it was aimed to present the case with solitary rectal ulcer perforation and discussed with recent literature.

CASE REPORT

Our case was a 168 cm tall, weighing 65-70 kg and 57-year-old male that was reported to be found dead in the watchman cabin in his workplace. According to the scene investigation report it was indicated that the victim was found on the couch in dormitory at workplace touching his feet to the floor, half sitting and lying on his left side and there was no signs of a mess or struggle in the scene investigation. No exact knowledge related to medical history of the dead person was reached. On gross external macroscopic examination yellow-green vomit smear around the mouth, 3x2 cm size of ecchymosis and two abrasions of 0.3 cm diameter on the right knee and a 1x0.5 cm size abrasion on the outer malleolus of left foot were observed. At the autopsy, in abdominal cavity, 200 ml of dirty green-brown colored fluid with a few particles of intestinal contents and yellow-green colored membranes on abdominal organs were observed. At the anterior wall of the rectum, 2x1.5 cm size perforation area was observed, after dissection, on rectal mucosa, ulcer with adjacent 1x0.5 cm of polypoid lesion, bleeding in the edges was examined (Fig. 2). In the stomach, about 50 ml of dirty brown colored fluid content was found. Stomach, small intestine mucosa and its walls were naturally observed. The heart weighed 380 g and being more intense in the descending branch of the left coronary artery, nonocclusive atherosclerotic changes in coronary arteries, on the left ventricular anterior wall of myocardial sections, scar area that shows white discoloration was detected. In histopathological examination; in the samples that were prepared by sections taken from identified perforation of rectal ulcer area revealed ulceration and total loss of the lamina propria and mucosa, submucosa, muscular layer, intense neutrophilic infiltration on serosal surface, hemorrhage on subserosal and serosal side (Fig. 3). In myocardial samples connective tissue composed of scar areas and congestion, in samples prepared by sections walls, edema, congestion and pigment-laden macrophages were observed. During the autopsy, as a result of the analysis of blood and urine samples there were reported none of the substances screened during toxicological analysis. Death was reported due to perforation of solitary rectal ulcer.

DISCUSSION

Besides clinical findings of solitary rectal ulcer that can be rarely seen in rectum can change depending on the underlying pathology and anatomic locations; anal region and abdominal pain, chronic gastrointestinal bleeding, constipation, mucus during defecation and may be rarely together with perforation (1,2,5,8,9). Findings detected with clinical and colonoscopy often are confused with chronic diseases of rectum such as malignancy and inflammatory bowel diseases, and a definite diagnosis must be confirmed with histopathological examination (1,5-8). Although solitary rectal ulcer formation mechanism is not fully understood, infectious causes such as tuberculosis and amoebiasis, ischemia, fecal impaction, radiation, local trauma and anorectal dysmotility have been implicated as etiologic factors (1,2,8). Solitary rectal ulcer syndrome defined in 1830 by Cruveilheir for the first time and a series consist of 68 patients was published in 1969 by Madigan and Morso (8). It was equally in frequency observed among men and women and majority of patients were diagnosed in early adulthood (30-40 ages) (5). The most recent mechanism alleged in the pathophysiology is the exposure to repetitive trauma due to strain during defecation of mucosa hanging from the rectal mucosal prolapse; development of ulcers as a result of induced ischemia due to deterioration of blood flow (10). On the other hand, especially in elderly patients due to frequently seen constipation and fecal impaction due to the pressure of hardened stool it is thought a necrotic edged ulcer (stercoral ulcer) developed and perforations are developed due to this (11). Although stercoral ulcer perforation is a rare condition it goes on with high mortality and morbidity (12,13). Unlike idiopathic colonic perforations in stercoral ulcer, usually perforations were associated with a ulcerative lesions and perforated area had necrotic appearance and was surrounded by an area that signs of inflammation monitored microscopically (14). Stercoral perforations are responsible for the 3.2% of entire colon perforation (15) and the highest mortality rate of 35% had been reported in the literature (16). Our patient whose perforation area of front wall of the rectum monitored surrounded by hyperemic area seems to be more compatible with stercoral ulcer perforation. No exact information obtained from the medical records that shows last medical status of case could be reached and occurring rectum perforation is considered caused by the developed stercoral ulcer. In the literature only one case has been reported about the stercoral fatal ulcer perforation case, unlike our case has been reported to be hospitalized two days before the death and died in the hospital with a history of gastrectomy and resection of the prostate despite the implementation of enema without a bowel movement for about 10 days before his death (17). Already to be uncommon events, and due to the majority of patients diagnosed before death, these cases were rarely encountered in forensic autopsy practice.

Correspondence address:

Bülent Eren, M.D.

Council of Forensic Medicine of Turkey

Bursa Morgue Department, 16010, Bursa, Turkey.

tel.: +90 224 222 03 47; fax: +090 224 225 51 70

e-mail: drbulenteren@gmail.com