What is stercoral colitis?

Stercoral Colitis: A Serious Inflammatory Condition of the Colon

Stercoral colitis is a rare but potentially life-threatening inflammatory condition of the colon caused by increased intraluminal pressure from impacted fecal matter, which can lead to bowel wall ischemia, ulceration, necrosis, and perforation if not promptly treated. 1

Pathophysiology

Stercoral colitis develops when hardened fecal matter (fecaloma) exerts excessive pressure on the colonic wall, leading to:

• Reduced blood flow to the bowel wall
• Inflammatory changes in the colonic mucosa
• Potential ischemic changes
• Risk of ulceration and perforation in severe cases

The pathophysiological mechanism involves:

• Pressure from impacted stool exceeding capillary perfusion pressure (>35 mmHg)
• Compromised mucosal blood flow
• Inflammatory cascade activation
• Potential transmural necrosis

Risk Factors

Patients at highest risk include:

• Elderly individuals
• Chronically constipated patients
• Nursing home residents
• Chronic opioid users
• Patients with neurological disorders (cerebral palsy, stroke, dementia) 2
• Patients with psychiatric disorders
• Bedridden patients
• Recent orthopedic surgery patients 3
• Patients with intellectual disabilities 4

Clinical Presentation

Patients typically present with:

• Abdominal pain (most common symptom)
• Chronic constipation
• Abdominal distension
• Nausea and vomiting
• Altered mental status (especially in patients with neurological disorders) 2
• Signs of sepsis or septic shock in advanced cases 4

Important to note that presentation may be atypical or minimal in:

• Elderly patients
• Patients with cognitive impairment
• Patients with neurological disorders

Diagnosis

The diagnosis is primarily radiological, with CT scan being the most valuable imaging modality 3:

Key CT findings include:

• Colonic dilatation with impacted feces (>6 cm in diameter)
• Focal colonic wall thickening (>3 mm)
• Pericolic fat stranding
• Mucosal sloughing
• Pericolonic soft tissue density
• Ascites or free fluid
• Extraluminal air or pneumoperitoneum (in cases of perforation)

Laboratory findings may include:

• Leukocytosis
• Elevated inflammatory markers
• Lactic acidosis (suggesting bowel ischemia) 5

Complications

Stercoral colitis can lead to several serious complications:

• Stercoral ulceration
• Ischemic colitis
• Bowel perforation
• Peritonitis
• Sepsis and septic shock
• Death (mortality rates up to 50% with perforation)

Notably, non-perforated stercoral colitis with septic shock may have higher mortality than perforated cases, emphasizing the need for early recognition and treatment 4.

Management

Treatment should be initiated promptly and includes:

1. Resuscitation and stabilization:

   • Intravenous fluid resuscitation
   • Correction of electrolyte abnormalities
   • Hemodynamic support if septic

2. Bowel decompression:

   • Multimodal bowel regimen (stool softeners, osmotic laxatives)
   • Enemas
   • Manual disimpaction when necessary
   • Colonoscopic disimpaction in selected cases 2

3. Antimicrobial therapy:

   • Broad-spectrum antibiotics if signs of infection, sepsis, or perforation

4. Surgical management:

   • Indicated for perforation, peritonitis, or failure of conservative management
   • May include colectomy with diversion (Hartmann's procedure) 4
   • Extended left colectomy may be necessary in cases of extensive disease

5. Prevention of recurrence:

   • Long-term bowel regimen
   • Treatment of underlying causes of constipation
   • Regular follow-up

Prognosis

The prognosis depends on:

• Timing of diagnosis and intervention
• Presence of complications (perforation, sepsis)
• Patient's comorbidities and functional status

Early recognition and treatment significantly improve outcomes, while delayed diagnosis is associated with high morbidity and mortality rates.

Key Points for Clinicians

• Maintain high clinical suspicion in high-risk patients with abdominal pain, even with minimal symptoms
• CT scan is the diagnostic modality of choice
• Elevated lactic acid may indicate bowel wall ischemia
• Early aggressive bowel decompression is essential to prevent perforation
• Consider surgical consultation early in the management
• All patients with stercoral colitis should be considered for hospital admission 1