Treatment of Constipation with Stercoral Colitis
The management of constipation with stercoral colitis requires immediate disimpaction of fecal material, followed by implementation of a maintenance bowel regimen to prevent recurrence and reduce the risk of serious complications such as perforation, peritonitis, and sepsis. 1, 2
Initial Management
- Begin with fluid resuscitation to correct dehydration and electrolyte imbalances that commonly accompany stercoral colitis 3
- Perform digital fragmentation and extraction of stool as the first-line intervention for distal fecal impaction, confirmed by digital rectal examination 1
- Follow disimpaction with enemas (water or oil retention) or suppositories to facilitate passage of stool through the anal canal 1
- For proximal fecal impaction without complete bowel obstruction, administer polyethylene glycol (PEG) solutions containing electrolytes to soften or wash out stool 1, 4
- Initiate parenteral antibiotics if there are signs of infection or concern for perforation 3
Ongoing Treatment
- Implement a maintenance bowel regimen immediately after disimpaction to prevent recurrence 1, 4
- Use osmotic laxatives (such as PEG) or stimulant laxatives as the preferred agents for ongoing management 1
- Avoid bulk-forming laxatives such as psyllium, which are not recommended and may worsen impaction 1
- Consider hospital admission for all patients with stercoral colitis due to high risk of complications and substantial short-term mortality 4
- Monitor with regular abdominal examinations and laboratory assessments to detect complications early 2, 3
Special Considerations
- For patients with opioid-induced constipation contributing to stercoral colitis, consider peripheral opioid antagonists such as methylnaltrexone or naloxegol 1
- In elderly patients, pay particular attention to medication review and withdrawal of inappropriate medications that may contribute to constipation 1
- For patients with neurological disorders (e.g., cerebral palsy) or altered mental status, maintain a high index of suspicion as symptoms may be atypical or difficult to assess 5
- Consider surgical consultation for patients with signs of perforation, peritonitis, or other severe complications 3
Monitoring and Follow-up
- Perform regular abdominal examinations to assess for resolution of impaction and development of complications 3
- Monitor vital signs and laboratory values (complete blood count, electrolytes, renal function) to detect deterioration early 2, 4
- Consider follow-up imaging to confirm resolution of colonic inflammation and fecal impaction in severe cases 4
Common Pitfalls and Caveats
- Failure to recognize stercoral colitis can lead to delayed treatment and increased risk of perforation, with mortality rates as high as 3.3% 4
- Many patients with stercoral colitis may not present with typical abdominal pain (absent in up to 62.1% of cases), requiring high clinical suspicion 4
- Inadequate treatment is common—over half of patients discharged from emergency departments receive no enema, laxatives, or disimpaction, increasing risk of complications 4
- Elevated lactic acid levels may indicate ischemia of the bowel wall, requiring more aggressive management 2
- Rapid return to normal bowel habits is essential to prevent recurrence of stercoral colitis 1, 3