Stercoral Colitis: Definition, Diagnosis, and Management
Stercoral colitis is an inflammatory condition of the colon caused by pressure necrosis from impacted fecal matter, which can lead to serious complications including bowel ulceration, ischemia, perforation, peritonitis, and sepsis if not promptly diagnosed and treated. 1
Clinical Presentation
Stercoral colitis typically presents with:
- Abdominal pain and distension (33.8% of cases) 2
- Constipation or history of chronic constipation
- Notably, abdominal pain may be absent in up to 62.1% of cases 2
- Non-specific symptoms that may include nausea, vomiting, and confusion 3
- Higher prevalence in elderly patients (median age 76 years) 2
Risk Factors
- Elderly population
- Chronic constipation
- Nursing home residents
- Chronic opioid users
- Patients with mental impairment or intellectual disability 3
- Recent surgery, particularly orthopedic procedures 4
Diagnostic Approach
Imaging
Computed tomography (CT) is the most valuable diagnostic tool, with characteristic findings including:
- Fecal impaction (present in 96.7% of cases) 2
- Bowel wall inflammation/thickening (72.9%) 2
- Pericolic fat stranding (48.3%) 2
- Colonic dilatation containing impacted feces 4
- Minimal free fluid in abdominal and pelvic cavities 4
Laboratory Tests
- Leukocytosis
- Elevated lactic acid (may indicate bowel wall ischemia) 5
- Stool evaluation to rule out infectious etiology 6
Complications
- Stercoral ulceration
- Ischemic colitis
- Bowel perforation
- Peritonitis
- Sepsis and septic shock
- Death (mortality rate approximately 3.3% within 3 months) 2
Management
Emergency Department Management
- Fluid resuscitation
- Multimodal bowel regimen including:
- Enemas
- Laxatives
- Manual disimpaction of stool 5
- Parenteral antibiotics if signs of infection or sepsis are present
- Surgical consultation for severe cases or when complications are suspected 1
Surgical Management
Surgical intervention is indicated in cases with:
- Perforation
- Peritonitis
- Bowel necrosis
- Septic shock unresponsive to medical management
The standard surgical approach is colectomy with diversion (such as Hartmann's procedure) for complicated cases 3
Important Considerations
- Hospitalization should be considered for all patients with stercoral colitis due to the high risk of complications 1
- Over half of patients discharged from the ED (53.6%) receive no enema, laxatives, or disimpaction, representing a concerning gap in appropriate management 2
- Non-perforated stercoral colitis with septic shock may have higher mortality than perforated cases, emphasizing the need for aggressive management even without perforation 3
- ED return rate within 72 hours is approximately 10%, highlighting the importance of close follow-up 2
Distinguishing from Other Colitis Types
Unlike inflammatory bowel diseases such as ulcerative colitis or Crohn's disease, stercoral colitis:
- Is not autoimmune in nature
- Has a direct mechanical cause (fecal impaction)
- Is not chronic (though may recur if underlying constipation is not addressed)
- Typically affects a more localized area at the site of impaction
- Does not respond to immunosuppressive therapies used for IBD 7
Early recognition and aggressive management of stercoral colitis are essential to prevent life-threatening complications and reduce mortality.