What is stercoral colitis?

What is Stercoral Colitis?

Stercoral colitis is a rare but potentially life-threatening inflammatory condition of the distal large bowel and rectum caused by accumulation of impacted fecal material, which compresses the vascular supply leading to bowel ischemia, ulceration, and potentially perforation, peritonitis, or sepsis 1, 2.

Pathophysiology

The condition develops when dense, dehydrated stool causes luminal distention that compresses the colonic vascular supply, resulting in:

• Bowel wall ischemia
• Mucosal ulceration
• Progressive inflammation
• Risk of perforation (occurs in approximately 29% of cases) 3

The inflammatory process can progress to ischemic colitis (45% of cases), bowel obstruction, bleeding, fistula formation, and even urinary tract involvement from mass effect 2, 4.

At-Risk Populations

Stercoral colitis primarily affects:

• Elderly patients (median age 76 years) 5
• Patients with chronic constipation (present in 76% of cases) 3
• Those with decreased bowel motility from:
  • Neurodegenerative disorders
  • Chronic medical diseases
  • Malignancy
  • Immobility/bedbound status
  • Narcotic or anticholinergic medication use (opioid exposure in 14% of cases) 2, 3, 6
  • Antipsychotic medications 4

Important caveat: While most common in elderly patients, stercoral colitis can occur in younger patients with risk factors for impaired bowel motility 2, 7.

Clinical Presentation

The presentation is often nonspecific and challenging, which contributes to underrecognition:

• Abdominal pain/distension is the most common chief complaint (34%) 5
• However, abdominal pain is absent in 62% of documented cases 5
• Other presentations include:
  • Constipation or paradoxical overflow diarrhea 6
  • Hematochezia
  • Nongastrointestinal symptoms
  • Urinary retention (from bladder compression by fecaloma) 4

Critical pitfall: The absence of abdominal pain does not exclude stercoral colitis—only 76% present with abdominal pain 3. The nonspecific presentation, combined with common comorbidities that complicate history-taking, makes imaging essential for diagnosis 2.

Diagnostic Approach

CT imaging is crucial and plays a vital role in diagnosis 2, 7, particularly when:

• Clinical presentation is atypical
• Elevated inflammatory markers (WBC, CRP, lactate) are present 3

Hallmark CT Findings:

• Fecal impaction/fecaloma (present in 97% of cases) 5
• Bowel wall thickening >3 mm (66% of cases) 3
• Pericolonic fat stranding (48% of cases) 5
• Colonic dilatation
• Large colorectal stool burden 2

Complications Identifiable on CT:

• Mural discontinuity (perforation)
• Extraluminal air
• Extraluminal stool collections
• Hydronephrosis/hydroureter from extrinsic compression 4

Diagnostic challenge: Findings can overlap with diverticulitis and malignancy. The key distinguishing feature is identification of fecal impaction with associated inflammatory changes 2.

Management Strategy

Treatment depends on disease severity and presence of complications:

Conservative Management (for uncomplicated cases):

• Aggressive fluid resuscitation
• Multimodal bowel regimen:
  • Manual disimpaction
  • Enemas
  • Laxatives
• Parenteral antibiotics if indicated 1

Critical error to avoid: In patients presenting with overflow diarrhea, do NOT use anti-motility agents—this carries high risk of colonic perforation 6.

Surgical Management:

Reserved for:

• Clinical deterioration
• Peritonitis
• Perforation
• Failed conservative therapy 3

Surgical mortality is substantial at 27% compared to 0% for non-operative management 3.

Outcomes and Prognosis

The condition carries significant morbidity and mortality:

• Overall in-hospital/30-day mortality: 22% 3
• 3-month disease-related mortality: 3.3% 5
• Surgical intervention required: 3.3% within 3 months 5
• ED return within 72 hours: 10% 5
• Recent large cohort data suggests adverse outcomes occur in only 2% of cases 8

Disposition Considerations

• Admission should be considered for all patients with stercoral colitis 1
• 71% of patients are hospitalized 8
• Of those discharged from the ED (29%), over half received no enema, laxatives, or disimpaction—representing a significant treatment gap 5
• Hospitalization decisions should be based on:
  • Need for hospital-based interventions
  • Assistance with bowel regimen
  • Overall clinical picture 8

The condition remains underrecognized despite its association with high morbidity, emphasizing the need for high clinical suspicion in at-risk patients with refractory constipation, even when typical symptoms are absent 1, 7.