Treatment of Stercoral Colitis
Stercoral colitis requires immediate aggressive medical management with IV fluids, multimodal bowel regimen, and thromboprophylaxis, with emergency surgery reserved for perforation, peritonitis, massive bleeding with hemodynamic instability, or failure to improve within 24-48 hours. 1, 2
Initial Medical Management
The cornerstone of treatment involves intensive supportive care and bowel decompression:
- Intravenous fluid and electrolyte replacement to correct dehydration and maintain adequate hydration, which is critical given the inflammatory state and potential for sepsis 1
- Multimodal bowel regimen including enemas, laxatives, and manual disimpaction to relieve fecal impaction 2, 3, 4
- Parenteral antibiotics should be initiated if there are signs of sepsis, elevated inflammatory markers, or concern for bowel ischemia 2, 5
- Subcutaneous heparin for thromboprophylaxis is essential, as inflammatory colonic conditions significantly increase thromboembolism risk 1
- Blood transfusion to maintain hemoglobin >10 g/dl if bleeding is present 1
Intensive Monitoring Protocol
Close surveillance is mandatory to detect early deterioration:
- Vital signs monitoring at least four times daily (more frequently if any clinical deterioration) 1
- Laboratory assessment every 24-48 hours including complete blood count, inflammatory markers (ESR/CRP), serum electrolytes, liver function tests, and lactate levels 1, 3
- Daily abdominal radiography if colonic dilatation is present (transverse colon diameter >5.5 cm) to monitor for progression or perforation 1
- Stool charting to document number, character, and presence of blood 6
A critical pitfall is missing the diagnosis in patients with altered mental status, elderly patients, or those with neurologic disorders who cannot communicate symptoms effectively—maintain high clinical suspicion in at-risk populations with chronic constipation or opioid use 2, 7.
Surgical Indications
Emergency surgery is mandatory in the following scenarios:
- Free perforation with generalized peritonitis requires immediate surgical exploration 6, 1
- Massive bleeding with hemodynamic instability unresponsive to resuscitation 6, 1
- Clinical deterioration with signs of shock despite medical management 6, 1
- No improvement or worsening within 24-48 hours of aggressive medical therapy 6, 1
Subtotal colectomy with ileostomy (Hartmann's procedure or extended left colectomy) is the surgical treatment of choice for severe stercoral colitis requiring operative intervention 6, 1, 5. This approach is preferred over limited resection given the often extensive nature of inflammation and ischemia.
Special Considerations
- Nutritional support (enteral or parenteral) should be provided to malnourished patients 1
- Endoscopic disimpaction is rarely used but may be considered in stable patients without perforation or severe ischemia 4
- Elevated lactate levels in conjunction with CT findings of bowel wall thickening and peri-colonic fat stranding strongly suggest concurrent ischemic colitis, which significantly increases mortality risk 3, 4
The mortality rate is substantial at 22.4% overall, with operative mortality reaching 26.9% 4. Notably, non-perforated cases presenting with septic shock may have higher mortality than perforated cases, emphasizing the importance of recognizing systemic deterioration even without frank perforation 5. All patients with stercoral colitis should be admitted to the hospital for close monitoring and escalation of care as needed 2.