Stercoral perforation with verapamil.

Sir, Constipation is the commonest and most troublesome non-cardiac side effect of verapamil use.', We would like to report a case of stercoral perforation in a woman taking verapamil. A 78 year old woman was admitted with sudden onset of lower abdominal pain associated with signs of generalized peritonitis. She had developed chronic constipation after commencement of verapamil for recurrent supraventricular tachycardia 9 months previously and prior to this time she had had a normal bowel habit. Two months prior to admission she had been found to be biochemically hypothyroid and was treated with thyroxine. On admission she was clinically and biochemically euthyroid. After resuscitation, laparotomy revealed a perforation in an otherwise normal sigmoid colon. The proximal and distal colon was loaded with scybalous stools. The peritoneum was lavaged and the perforated colon exteriorized. Postoperatively the patient suffered from recurrent supraventricular tachycardias until verapamil was recommenced on the third day. This was followed by a prolonged (13 day) ileus which rapidly resolved on substituting atenolol for verapamil. Previous reports of gut immotility secondary to verapamil describe patients susceptible to constipation because of underlying medical conditions.3 Our patient had been diagnosed as being hypothyroid in the recent past, although she was clinically and biochemically euthyroid on admission. Serpell and Nichols' review of colonic stercoral perforation notes that scybalum formation may occur months prior to perforation, as it takes time to traumatize and breach the intestine.4 It is possible that hypothyroidism was a contributing factor to this patient's stercoral perforation but it is unlikely to be the sole cause. There are virtually no reports of hypothyroidism causing intestinal perforation or immotility other than a case of fatal intestinal atony attributed to myxoedema in 1969.5 It is therefore most likely that verapamil was the major cause of this patient's perforation, with hypothyroidism as a possible exacerbating factor. Verapamil significantly reduces motor activity of the intestine; this returns to normal on cessation of the drug.2 Severe constipation is frequently described as one of the most troublesome side effects of verapamil use. We suggest that verapamil should be used with caution in patients with pre-existing tendency to constipation and that its use should be reviewed if other factors which exacerbate constipation develop during treatment.