17.9.24

The sad and unfortulate story of Amarjit Singh

A 63-year-old male was operated at some private hospital (laparotomy) on 20-6-2024 for massive pneumoperitoneum on abdominal X-ray. The CT on 19.6.24 had shown massive air in peritoneal cavity, slight wall thickening of proximal jejunal loops, a loaded right colon, and the left colon fluid filled and with a wall thickness of up to 10 mm. At laparotomy, the surgeon had found no perforation, but a dilated left colon full of fecal matter and gas which was removed by the rectal tube, and he was prescribed laxatives for constipation; the discharge slip ,mentioning the possibility of a sealed perforation, and a possible diagnosis of toxic megacolon. Was brought to me in a very emaciated condition after the sutures had been removed. However, he still reported that he is constipated, and his abdomen was still found to be distended. A detailed history taken at this time revealed that he was constipated since childhood and has been taking pink tablets (phenolphthalein) regularly for constipation. The treating hospital did make efforts to make a diagnosis with colonoscopy (9.7.24) which showed a small ulcerated nodule 10 cm from anal verge, and later on 23.7.24 a barium enema showed a hugely distended left colon. His general condition continued to worsen, he lost all appetite, became depressed and stopped eating because he did not feel like eating. I could only prescribe regular enemas besides all sorts of other laxatives for him, but he did not improve and eventually died on 17.9.24.

This was a shocking and tragic experience when a patient with possibly congenital constipation which he had been managing with laxatives (phenolphthalein) all his 60 plus years suddenly landing up with acute abdominal pain and distension needing a laparotomy, and his constipation still could not be managed even after operation despite all sorts of medications for constipation and enemas.

A literature search came up with just one report of two cases dying of constipation (Constipation can be deadly. Canadian family physician, vol 38, oct 1992). It concluded that a digital rectal examination can be normal, because stool remains impacted high up, manual disimpaction may not be sufficient and so more is needed. It recommended vigorous use of enemas, and laxatives/osmotic agents orally. However, we tried all these till the end, without success.