Risks Associated with Stercoral Proctitis
Stercoral proctitis can lead to life-threatening complications including bowel perforation, peritonitis, sepsis, and death, particularly in chronically constipated or immunocompromised patients.
Definition and Pathophysiology
Stercoral proctitis refers to inflammation of the rectum caused by pressure from hardened fecal matter (fecaloma). This condition typically occurs in patients with chronic constipation, where prolonged pressure from impacted stool leads to:
- Mucosal ischemia
- Inflammation
- Ulceration of the rectal wall
Major Complications
1. Stercoral Ulceration
- Results from pressure necrosis of the colonic/rectal wall by hard fecaloma
- Typically occurs at antimesentric border where blood supply is poorest
- Can progress to full-thickness damage of the bowel wall
2. Bowel Perforation
- Most serious and life-threatening complication
- Occurs when pressure necrosis extends through all layers of the bowel wall 1, 2
- Commonly affects the rectosigmoid region
- Presents with acute abdominal pain, peritonitis, and sepsis
3. Peritonitis
- Results from fecal contamination of the peritoneal cavity following perforation
- Presents with:
- Abdominal rigidity
- Rebound tenderness
- Fever
- Hypotension/shock
4. Systemic Complications
- Pneumoperitoneum (free air in peritoneal cavity)
- Pneumomediastinum and subcutaneous emphysema in severe cases 1
- Sepsis and septic shock
- Multi-organ failure
5. Hemorrhage
- Can occur from erosion into blood vessels
- May present as hematochezia or melena
- Can be life-threatening, especially in elderly or anticoagulated patients
High-Risk Populations
Patients at increased risk for complications include:
- Elderly patients
- Chronically bedridden individuals
- Psychiatric patients on anticholinergic medications 3
- Patients with neurological disorders affecting bowel motility
- Immunocompromised patients (e.g., those with SLE, on steroids) 2
- Patients on medications that slow intestinal motility
Mortality Risk
- Perforation and hemorrhage from stercoral ulceration carry a mortality rate exceeding 50% 4
- Early diagnosis and intervention are critical to reducing mortality
Diagnostic Considerations
- Plain radiographs may show pneumoperitoneum (air under diaphragm) in cases of perforation
- CT scan is the most sensitive for detecting perforation and fecal loading
- Anoscopy or sigmoidoscopy may reveal ulceration or impacted stool
Prevention
To prevent complications of stercoral proctitis:
- Aggressive management of chronic constipation
- Regular bowel regimens for at-risk patients
- Prompt disimpaction of fecal matter when identified
- Adequate hydration and fiber intake
Clinical Pearls and Pitfalls
- Stercoral perforation should be considered in any patient with chronic constipation who develops acute abdominal pain
- The diagnosis is often delayed due to atypical presentation, especially in elderly or immunocompromised patients
- Early surgical consultation is essential when perforation is suspected
- Mortality remains high despite advances in critical care and surgical techniques
Remember that what appears as simple constipation can evolve into a life-threatening surgical emergency if stercoral proctitis progresses to perforation.