Treatment of Stercoral Colitis
The treatment of stercoral colitis requires aggressive medical management with IV fluids, multimodal bowel regimen, thromboprophylaxis, and close monitoring, with immediate surgical intervention (subtotal colectomy with ileostomy) reserved for patients with perforation, massive bleeding with hemodynamic instability, or clinical deterioration despite medical therapy. 1, 2
Initial Medical Management
The cornerstone of treatment involves supportive care and fecal disimpaction:
- Intravenous fluid and electrolyte replacement to correct dehydration and maintain adequate hydration 1
- Multimodal bowel regimen including laxatives, enemas, and manual disimpaction to relieve the fecal impaction 2, 3
- Subcutaneous heparin for thromboprophylaxis given the increased thromboembolism risk from inflammatory conditions 1
- Blood transfusion to maintain hemoglobin >10 g/dl if bleeding is present 1
- Parenteral antibiotics should be initiated if there are signs of sepsis or concern for bowel ischemia/necrosis 2, 4
- Nutritional support (enteral or parenteral) for malnourished patients 1
Monitoring Requirements
Vigilant monitoring is essential to detect early deterioration:
- Vital signs monitoring at least four times daily to identify clinical deterioration 1
- Daily abdominal radiography if colonic dilatation is present (transverse colon diameter >5.5 cm) 1
- Laboratory monitoring every 24-48 hours including complete blood count, inflammatory markers (ESR/CRP), serum electrolytes, albumin, and liver function tests 1
- Serial lactate measurements as lactic acidosis may indicate bowel ischemia 3
Indications for Emergency Surgery
Immediate surgical exploration is mandatory in the following scenarios 5, 1:
- Free perforation with generalized peritonitis 5
- Massive bleeding with hemodynamic instability unresponsive to resuscitation 5
- Clinical deterioration and signs of shock 5
- No improvement or worsening within 24-48 hours of aggressive medical management 5
Subtotal colectomy with ileostomy is the surgical treatment of choice for severe stercoral colitis requiring operative intervention 5, 1
Special Considerations and Pitfalls
- Non-perforated stercoral colitis with septic shock carries higher mortality than perforated cases, emphasizing the need for aggressive early intervention 4
- Transmural necrosis can occur without perforation, making clinical assessment challenging 4
- Elderly patients, chronic opioid users, and those with mental impairment are at highest risk and may present with atypical symptoms including altered mental status rather than typical abdominal pain 4, 6
- CT scan is the diagnostic modality of choice, showing impacted feces, colonic dilatation, mural thickening, and pericolic fat stranding 2, 7
- Colonoscopy with fecal disimpaction can be therapeutic in stable patients without perforation 6
- All patients with stercoral colitis should be admitted to the hospital given the high risk of complications 2