What is Stercoral Colitis?
Stercoral colitis is a rare but potentially life-threatening inflammatory condition of the colon caused by impacted fecal material (fecaloma) that leads to pressure-induced mucosal injury, colonic wall inflammation, and can progress to ulceration, ischemia, perforation, peritonitis, and sepsis. 1, 2
Pathophysiology and Risk Factors
Stercoral colitis develops when hardened, dehydrated stool accumulates and exerts chronic pressure on the colonic wall, causing direct mechanical injury and compromising blood flow to the mucosa. 3 The condition primarily affects:
- Elderly or bedbound patients with chronic constipation as the most common demographic 1, 4
- Patients with comorbidities including diabetes, cardiac disease, Alzheimer's disease, or recent orthopedic surgery (particularly hip fractures) 3, 5
- Younger patients with conditions predisposing to severe constipation (though less common) 1
The rectosigmoid colon is the most frequently affected segment due to its anatomical narrowing and the tendency for stool to accumulate in this region. 5
Clinical Presentation
The clinical picture is often nonspecific and varied, making diagnosis challenging:
- Abdominal pain and distension are the most common presenting symptoms 2, 3
- Constipation or absence of bowel movements for several days 3, 5
- Many patients present without typical symptoms, requiring high clinical suspicion in at-risk populations 2
- Physical examination may reveal abdominal distension with tenderness, though findings can be subtle 3
Critical pitfall: Stercoral colitis can mimic other colonic pathologies including diverticulitis, ischemic colitis, and inflammatory bowel disease, contributing to diagnostic delays. 4
Diagnostic Approach
Computed tomography (CT) of the abdomen and pelvis is the most helpful imaging modality and crucial for diagnosis. 1, 3 Key CT findings include:
- Fecaloma (large collection of impacted fecal material) 1, 2
- Colonic dilatation containing impacted feces 3
- Focal mural thickening of the affected colonic segment 1, 3
- Pericolic fat stranding indicating inflammation 1, 3
- Free fluid in the abdominal/pelvic cavities (may indicate impending or actual perforation) 3
Plain abdominal radiographs may show bowel distention and fecal material but are insufficient for definitive diagnosis. 3
Management Strategy
Treatment depends on disease severity and presence of complications:
Uncomplicated Cases (Most Common)
- Fluid resuscitation to address dehydration 2
- Multimodal bowel regimen including stool softeners, osmotic laxatives, and stimulant laxatives 2
- Manual disimpaction when appropriate 1
- Conservative management with close monitoring 3
Complicated Cases (Perforation, Peritonitis, Sepsis)
- Immediate surgical consultation is mandatory 2, 5
- Parenteral antibiotics for peritonitis or sepsis 2
- Emergency surgical intervention (typically colectomy with or without primary anastomosis) for stercoral perforation 5
All patients with stercoral colitis should be considered for hospital admission given the risk of rapid deterioration and life-threatening complications. 2
Prognosis and Complications
Stercoral colitis is associated with significant morbidity and mortality, particularly when complicated by perforation. 1, 4 Stercoral perforation represents a surgical emergency with rapid progression to peritonitis and bacteremia if not promptly recognized and treated. 5
Key clinical caveat: The condition remains underrecognized in emergency departments despite its serious nature, emphasizing the need for heightened awareness in at-risk populations. 1 Emergency clinicians must maintain high clinical suspicion, especially in elderly patients with chronic constipation presenting with abdominal complaints, even when symptoms are atypical. 2