Management of Stercoral Proctitis
The management of stercoral proctitis requires prompt treatment of fecal impaction through manual disimpaction, enemas, and laxatives, followed by measures to prevent recurrence and monitoring for complications such as perforation. This approach addresses the underlying cause of pressure necrosis while preventing potentially life-threatening complications.
Initial Assessment and Management
Immediate Interventions
- Fecal disimpaction: The first priority is to relieve the fecal impaction causing pressure on the rectal wall
- Manual disimpaction for accessible impacted stool
- Enemas (mineral oil, sodium phosphate) to soften and facilitate passage of impacted stool
- High-volume tap water enemas may be necessary for severe impaction
Medical Management
- Laxative therapy:
- Osmotic laxatives (polyethylene glycol, lactulose)
- Stimulant laxatives (bisacodyl, senna) for more resistant cases
- Pain management: Mild analgesics as needed, avoiding opioids which can worsen constipation
- Assess for proximal constipation: Abdominal X-ray to evaluate for additional fecal loading in the proximal colon 1
- Antibiotic therapy: Consider if signs of infection or inflammation are present
Prevention of Recurrence
- Bowel regimen:
- Regular osmotic laxatives
- Adequate hydration (minimum 2L fluid daily)
- High-fiber diet (20-30g daily) unless contraindicated
- Regular physical activity
- Identify and address contributing factors:
- Review and modify medications that cause constipation
- Treat underlying conditions (hypothyroidism, diabetes, neurological disorders)
- Address mobility issues
Monitoring and Follow-up
- Regular follow-up: Initially weekly until symptoms resolve, then monthly
- Surveillance for complications:
- Monitor for signs of perforation (severe pain, fever, peritoneal signs)
- CT imaging if perforation is suspected 2
- Patient education:
- Warning signs requiring immediate medical attention
- Importance of adherence to bowel regimen
Management of Complications
Stercoral Colitis/Severe Inflammation
- Hospitalization for severe cases with signs of colitis
- Bowel rest: NPO status initially
- IV hydration
- Broad-spectrum antibiotics if signs of infection
Stercoral Perforation
- Surgical consultation immediately if perforation is suspected
- Emergency laparotomy with:
- Intensive postoperative care with close monitoring for sepsis
Special Considerations
Psychiatric patients: Higher risk due to medication side effects and poor self-care 4, 5
- More aggressive bowel regimens
- Closer monitoring
- Coordination with psychiatric care providers
Elderly and immobile patients: Higher risk population
- More frequent assessment
- Consider prophylactic bowel regimens
- Early intervention for even mild constipation
Patients on chronic medications: Review and modify medications that contribute to constipation
- Anticholinergics
- Opioids
- Calcium channel blockers
- Iron supplements
The mortality from stercoral perforation can be as high as 60% 5, making early recognition and aggressive management of stercoral proctitis essential to prevent this life-threatening complication.