What is the management of stercoral colitis?

Management of Stercoral Colitis

Urgent treatment with fluid resuscitation, multimodal bowel regimen including enemas and manual disimpaction, and broad-spectrum antibiotics is essential for managing stercoral colitis to prevent life-threatening complications such as perforation, peritonitis, and sepsis. 1, 2

Diagnosis and Initial Assessment

• Clinical presentation:

  • Most common: Abdominal pain and distension (33.8% of cases)
  • Note: Abdominal pain may be absent in up to 62.1% of cases 2
  • Other symptoms: Constipation, nausea, vomiting
  • High-risk populations: Elderly, nursing home residents, chronic opioid users, patients with mental impairment 3

• Laboratory evaluation:

  • Complete blood count (check for leukocytosis)
  • Inflammatory markers
  • Lactic acid (elevated in cases with ischemic component) 4
  • Electrolytes and renal function

• Imaging:

  • CT scan of abdomen/pelvis is the gold standard showing:
    • Fecal impaction (96.7% of cases)
    • Bowel wall inflammation/thickening (72.9%)
    • Pericolic fat stranding (48.3%)
    • Free fluid in severe cases 5, 2

Treatment Algorithm

1. Immediate Interventions (First 24 hours)

• Fluid resuscitation:

  • Intravenous fluids to correct dehydration and electrolyte imbalances 1

• Bowel decompression:

  • Enemas (first-line) 4, 1
  • Manual disimpaction of stool 4
  • Oral laxatives (if patient can tolerate) 1

• Antimicrobial therapy:

  • Initiate broad-spectrum antibiotics if signs of infection/sepsis present
  • Coverage should include gram-negative aerobic/facultative bacilli, gram-positive streptococci, and obligate anaerobic bacilli 6

• VTE prophylaxis:

  • Low-molecular-weight heparin and compression stockings due to high thrombotic risk in inflammatory colitis 6

2. Ongoing Management

• Monitoring:

  • Serial abdominal examinations
  • Repeat laboratory tests to track inflammatory markers
  • Consider repeat imaging if clinical deterioration

• Continued bowel regimen:

  • Ongoing stool softeners and laxatives
  • Consider polyethylene glycol solutions for maintenance

• Nutritional support:

  • Nutritional assessment and support as needed 6

3. Management of Complications

• For septic shock:

  • Aggressive fluid resuscitation
  • Vasopressors if needed
  • Note: Non-perforated stercoral colitis with septic shock may have higher mortality than perforated cases 3

• For suspected perforation:

  • Immediate surgical consultation
  • Extended colectomy with diversion (Hartmann's procedure) is often required 3

• For ischemic colitis component:

  • More aggressive management with close monitoring
  • Lower threshold for surgical intervention 4

Disposition

• Hospital admission should be considered for all patients with stercoral colitis 1, 2
• ICU admission for patients with:
  • Hemodynamic instability
  • Signs of sepsis/septic shock
  • Significant comorbidities
  • Suspected perforation or ischemia

Pitfalls and Caveats

• Delayed diagnosis: Stercoral colitis can present with nonspecific symptoms; maintain high clinical suspicion in high-risk patients 1

• Inadequate treatment: A study found that 53.6% of discharged patients received no enema, laxatives, or disimpaction, highlighting the importance of aggressive bowel management 2

• Failure to recognize complications: Mortality is substantial (3.3% within 3 months) with complications including stercoral ulcer, perforation, ischemic colitis, and sepsis 2

• Overlooking VTE prophylaxis: Essential in all colitis patients due to high thrombotic risk 6

• Discharge without adequate follow-up: 10% of patients return to the ED within 72 hours, suggesting need for close follow-up and clear discharge instructions 2