C45-21 A Rare Case of a Fecothorax as a Complication of a Herniated Small Bowel Obstruction

Abstract Fecothorax is an extremely rare hydrothorax variant, typically arising from fistulous diseases such as Crohn’s or traumatic colonic herniation into the pleural space. Contamination of the pleural space with stool promotes a significant inflammatory response and rapid clinical deterioration if not managed promptly. A 51-year-old male with a history of gastroesophageal reflux disease and obesity presented with worsening abdominal pain, nausea, and vomiting. He was tachycardic and hypoxic but improved with supplemental oxygen. Physical exam revealed a large left-sided lateral hernia without overlying skin changes. CT abdomen/pelvis confirmed small bowel obstruction (SBO) with questionable incarceration and a large hernia containing small bowel, colon, and spleen. A moderate left pleural effusion and bibasilar disease were also seen. Broad-spectrum antibiotics were started and general surgery was consulted. His hernia and SBO were managed conservatively, as his elevated BMI likely precluded successful repair. After several days of stability, he developed acute hypoxic respiratory failure following an aspiration event requiring ICU readmission. CT angiogram of the chest revealed a large loculated left pleural effusion. Repeat abdominal imaging showed a higher-grade SBO, secondary herniation along the lateral aspect of the primary hernia, and a new extraperitoneal fluid collection beneath the abdominal wall musculature. The patient was taken to the OR urgently. Fecal material was drained via left-sided Wayne tube thoracostomy, and a strangulated, perforated small bowel segment was resected. A large collection of bowel contents had tracked cephalad along fascial planes, decompressing into the left hemithorax. Enterococcus species grew from pleural cultures. Postoperatively, his condition stabilized; however, persistent purulent drainage necessitated left lung decortication, as fibrinolytics were contraindicated due to recent surgery. He recovered and was discharged, ultimately declining post-hospital follow-up due to marked clinical improvement. This case highlights an exceptionally rare presentation requiring emergent surgery. What sets this case apart is the unique path of contamination—the intra-abdominal fluid collection dissected the fascial planes, creating a communication to the left hemithorax, whereas most aberrant connections form between the bowel and diaphragm. Despite initial management with tube thoracostomy and aggressive pleural washout, the patient developed an enterococcal empyema, ultimately requiring video-assisted thoracic decortication. Unfortunately, the limited number of cases of fecothorax limits comprehensive understanding of its optimal management and outcomes. Given the high bacterial burden from stool exposure and the apparent increased risk of empyema, earlier definitive intervention with decortication may be warranted in the clinical course. This abstract is funded by: None