Treatment of Stercoral Colitis
The treatment of stercoral colitis requires immediate fecal disimpaction, aggressive bowel regimen, fluid resuscitation, and close monitoring for complications including perforation and sepsis. 1
Pathophysiology and Presentation
Stercoral colitis is an inflammatory condition of the colon caused by increased intraluminal pressure from impacted fecal matter, primarily affecting the distal colon and rectum. It can lead to serious complications including:
- Bowel wall ulceration and ischemia
- Colonic perforation
- Peritonitis
- Sepsis and septic shock
Patients typically present with:
- Abdominal pain and distension
- History of chronic constipation
- Nausea and vomiting
- Altered mental status (particularly in elderly or neurologically impaired patients) 2
Diagnostic Approach
Diagnosis is primarily made through cross-sectional imaging:
- CT scan findings (most helpful diagnostic tool):
- Colonic dilatation with impacted feces
- Colonic wall thickening (>3mm)
- Pericolonic fat stranding
- Free fluid in the abdomen/pelvis
- Pneumoperitoneum (if perforation has occurred) 3
Treatment Algorithm
1. Initial Management (First 24 Hours)
Fluid resuscitation:
Fecal disimpaction:
- Enemas (if no evidence of perforation)
- Manual disimpaction under appropriate analgesia
- Consider colonoscopic disimpaction in selected cases 5
Multimodal bowel regimen:
- Oral laxatives (if patient can tolerate oral intake)
- Rectal suppositories
- Avoid antiperistaltic agents and opiates 4
Antibiotic therapy:
- If signs of infection/sepsis are present
- Consider metronidazole (500 mg IV TID) if infection cannot be ruled out 4
2. Monitoring and Escalation of Care
- Close monitoring of vital signs
- Serial abdominal examinations
- Laboratory monitoring (CBC, electrolytes, lactate)
- Repeat imaging if clinical deterioration occurs
3. Surgical Management
Indications for urgent surgical intervention:
- Free perforation
- Generalized peritonitis
- Life-threatening hemorrhage with hemodynamic instability
- Clinical deterioration despite medical management
- Signs of septic shock 4
Surgical procedure of choice:
- Subtotal colectomy with ileostomy for severe cases with perforation or massive hemorrhage 4
- Limited resection may be considered in selected cases with focal disease 6
Special Considerations
High-Risk Populations
- Elderly patients
- Chronic opioid users
- Patients with neurological disorders or intellectual disabilities
- Nursing home residents 6
Complications to Monitor
- Stercoral ulceration
- Ischemic colitis (may be indicated by elevated lactate levels) 5
- Perforation
- Septic shock (carries higher mortality even in non-perforated cases) 6
Follow-up Care
- Maintenance bowel regimen to prevent recurrence
- Education on dietary modifications (increased fiber and fluid intake)
- Consider underlying causes of chronic constipation
- Evaluation for restoration of intestinal continuity if colectomy was performed
Common Pitfalls
- Delayed diagnosis, especially in patients with altered mental status or inability to communicate symptoms
- Failure to recognize sepsis in the absence of perforation
- Inadequate disimpaction leading to continued pressure on the bowel wall
- Overaggressive manual disimpaction risking iatrogenic perforation
Early recognition and aggressive treatment of stercoral colitis are essential to prevent life-threatening complications and reduce mortality.