What is stercoral colitis?

Stercoral Colitis: Diagnosis and Management

Stercoral colitis is a rare but serious inflammatory condition of the colon caused by fecal impaction, which can lead to pressure necrosis, ulceration, and potentially life-threatening complications including perforation, peritonitis, and sepsis if not promptly diagnosed and treated.

Definition and Pathophysiology

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

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

Unlike ulcerative colitis or Crohn's disease, stercoral colitis is not an inflammatory bowel disease but rather a mechanical complication of severe constipation.

Risk Factors

• Elderly patients (median age 76 years) 1
• Chronic constipation
• Nursing home residents
• Chronic opioid use
• Mental impairment or intellectual disability 2
• Immobility
• Neurological disorders affecting bowel motility
• Dehydration

Clinical Presentation

The presentation can be variable and often nonspecific:

• Abdominal pain and distension (33.8% of cases) 1
• Important caveat: Abdominal pain may be absent in up to 62.1% of cases 1
• Constipation
• Nausea and vomiting
• Altered mental status
• Fever (in cases with inflammation or infection)
• Hemodynamic instability or shock in severe cases

Diagnosis

Imaging

CT scan is the diagnostic modality of choice, with characteristic findings including:

• Fecal impaction (present in 96.7% of cases) 1
• Colonic wall thickening/inflammation (72.9%) 1
• Peri-colonic fat stranding (48.3%) 1
• Luminal distention
• Possible evidence of perforation in advanced cases

Laboratory Tests

• Complete blood count (leukocytosis)
• Inflammatory markers (elevated CRP, ESR)
• Lactic acid (may be elevated due to bowel wall ischemia) 3
• Electrolytes and renal function
• Blood cultures if sepsis is suspected

Management Algorithm

1. Initial Assessment and Stabilization

• Fluid resuscitation
• Correction of electrolyte abnormalities
• Hemodynamic monitoring
• Pain management (caution with opioids)

2. Medical Management (for non-perforated cases)

• Bowel decompression is the cornerstone of treatment:
  • Enemas
  • Oral laxatives (if patient can tolerate)
  • Manual disimpaction under appropriate analgesia
• Broad-spectrum antibiotics if signs of infection or sepsis
• Close monitoring for clinical deterioration

3. Surgical Management

• Indications for urgent surgical intervention:
  • Perforation
  • Peritonitis
  • Septic shock
  • Failure of medical management with worsening clinical status
  • Evidence of bowel necrosis
• Surgical options include:
  • Segmental colectomy with primary anastomosis or diversion (Hartmann's procedure)
  • Extended colectomy in cases of extensive involvement

Complications and Outcomes

• Perforation (high mortality risk)
• Peritonitis
• Sepsis and septic shock
• Mortality rate approximately 3.3% within 3 months 1
• ED return rate within 72 hours: 10% 1

Important Clinical Pearls

1. High index of suspicion is crucial, especially in elderly patients with chronic constipation and nonspecific symptoms.

2. Absence of abdominal pain does not rule out stercoral colitis - over 60% of patients may not report pain despite significant pathology 1.

3. Non-perforated stercoral colitis with septic shock can have higher mortality than perforated cases, highlighting the importance of early recognition and treatment 2.

4. Discharge without proper bowel management is dangerous - over half of patients discharged from the ED receive no enema, laxatives, or disimpaction, potentially leading to complications 1.

5. Prevention strategies should be implemented for high-risk patients, including:

   • Regular bowel regimens
   • Adequate hydration
   • Minimizing constipating medications
   • Mobility enhancement

Differential Diagnosis

• Diverticulitis
• Ischemic colitis
• Inflammatory bowel disease
• Infectious colitis
• Pseudomembranous colitis
• Malignancy

Stercoral colitis must be distinguished from other forms of colitis through careful clinical evaluation and appropriate imaging studies to ensure proper management and prevent life-threatening complications.