What is the management of stercoral colitis?

Management of Stercoral Colitis

Urgent treatment with laxatives, fecal disimpaction, IV fluids, and antibiotics is the cornerstone of management for stercoral colitis to prevent life-threatening complications such as perforation, peritonitis, and sepsis. 1

Diagnosis and Assessment

• Clinical Presentation:

  • Most commonly presents with abdominal pain and constipation
  • Some patients may present without typical symptoms, requiring high clinical suspicion
  • Risk factors include elderly patients, nursing home residents, chronic opioid users, and patients with mental impairment 1, 2

• Diagnostic Imaging:

  • CT scan is the most helpful imaging modality, showing:
    • Colonic dilatation with impacted feces
    • Bowel wall thickening
    • Pericolic fat stranding
    • Possible free fluid 3
  • Abdominal radiographs may show bowel distention and fecal material 3

Management Algorithm

1. Initial Stabilization and Medical Management

• Fluid Resuscitation:

  • Aggressive IV fluid therapy to correct dehydration 1
  • Monitor for hemodynamic instability

• Multimodal Bowel Regimen:

  • Enemas
  • Oral and/or rectal laxatives
  • Manual disimpaction of stool 4

• Antibiotic Therapy:

  • Initiate parenteral antibiotics if signs of infection or sepsis are present 1
  • Cover gram-negative and anaerobic organisms

• Laboratory Monitoring:

  • Daily monitoring of vital signs
  • Complete blood count
  • Comprehensive metabolic panel
  • Lactic acid levels (elevated levels may indicate bowel wall ischemia) 4

2. Surgical Consultation and Intervention

• Indications for Surgical Consultation:

  • All patients with stercoral colitis should be evaluated by a surgical specialist 1

• Indications for Urgent Surgery:

  • Signs of perforation (pneumoperitoneum)
  • Peritonitis
  • Septic shock
  • Bowel necrosis
  • Failure to respond to conservative management 2

• Surgical Approach:

  • Extended left colectomy and Hartmann's procedure is often required in severe cases 2
  • Subtotal colectomy with ileostomy may be necessary in extensive disease 5

3. Hospital Admission and Monitoring

• Admission Criteria:

  • Hospital admission should be considered for all patients with stercoral colitis 1

• Monitoring During Hospitalization:

  • Daily abdominal examinations
  • Serial laboratory tests
  • Repeat imaging if clinical deterioration occurs

Complications and Pitfalls

• Potential Complications:

  • Stercoral ulcer formation
  • Ischemic colitis
  • Perforation
  • Peritonitis
  • Sepsis
  • Death 4, 2

• Common Pitfalls:

  • Delayed diagnosis due to vague symptoms
  • Misdiagnosis as diverticulitis (they may coexist) 6
  • Delayed escalation of therapy leading to poor outcomes 5
  • Failure to recognize the severity of the condition

Special Considerations

• High-Risk Populations:

  • Elderly patients
  • Patients with chronic constipation
  • Nursing home residents
  • Chronic opioid users
  • Patients with mental impairment 2
  • Recent surgery patients (especially orthopedic) 3

• Preventive Measures:

  • Regular bowel regimen for high-risk patients
  • Avoidance of opioids when possible 5
  • Dietary modifications and increased fluid intake

Prognosis

• Non-perforated stercoral colitis patients with septic shock may have higher mortality than those with perforation 2
• Early recognition and aggressive management improve outcomes
• Patients may require long-term bowel management to prevent recurrence