Management of Stercoral Colitis
Stercoral colitis requires immediate aggressive medical management with IV fluids, bowel decompression, and close monitoring, with emergency surgery reserved for perforation, hemodynamic instability, or clinical deterioration despite medical therapy. 1
Initial Assessment and Risk Stratification
Stercoral colitis is a rare inflammatory condition caused by fecal impaction that carries significant mortality risk, particularly when complicated by sepsis, ischemia, or perforation. 2, 3 The diagnosis is secured with CT abdomen/pelvis showing fecaloma, colonic dilatation, bowel wall thickening, and peri-colonic fat stranding. 3, 4
High-risk patients include: elderly or bedbound individuals, chronic opioid users, patients with mental impairment or chronic constipation, and those with comorbidities predisposing to fecal impaction. 2, 3
Medical Management (First-Line for Stable Patients)
Immediate Interventions
- IV fluid and electrolyte replacement to correct dehydration and maintain adequate hydration 1
- Vital signs monitoring at minimum four times daily, more frequently if any deterioration noted 1
- Subcutaneous heparin for thromboprophylaxis given the inflammatory state increases thromboembolism risk 1
- Multimodal bowel regimen including enemas, laxatives, and manual disimpaction of stool 4, 5
Laboratory Monitoring
- Complete blood count, inflammatory markers (CRP/ESR), serum electrolytes, and liver function tests every 24-48 hours to assess treatment response and identify complications 1
- Blood transfusion to maintain hemoglobin >10 g/dL if bleeding occurs 1
Imaging Surveillance
- Daily abdominal radiography if colonic dilatation present (transverse colon diameter >5.5 cm) to monitor for toxic megacolon or perforation 1
- Low threshold for repeat CT if clinical deterioration occurs 1
Antibiotic Therapy
- Parenteral antibiotics should be initiated if signs of sepsis, bowel necrosis, or perforation are present 4
Nutritional Support
- Enteral or parenteral nutrition for malnourished patients 1
Surgical Management (For Complicated Cases)
Emergency surgery is mandatory in the following scenarios: 1
- Free perforation with generalized peritonitis
- Massive bleeding with hemodynamic instability unresponsive to resuscitation
- Clinical deterioration and signs of shock
- No improvement or worsening within 24-48 hours of aggressive medical therapy
The surgical procedure of choice is subtotal colectomy with ileostomy for severe stercoral colitis with complications. 1 This approach is definitive and prevents ongoing sepsis from necrotic bowel.
Critical Pitfalls to Avoid
- Do not delay treatment in patients presenting with septic shock, as non-perforated stercoral colitis with sepsis carries higher mortality than perforated cases 2
- Do not use anti-diarrheal medications in any patient with suspected stercoral colitis 6
- Do not miss the diagnosis in younger patients—while elderly are most commonly affected, stercoral colitis does occur in younger individuals with risk factors 3
- Maintain high clinical suspicion as presentation is often nonspecific and varied, without typical constipation symptoms in many cases 3, 4
Multidisciplinary Approach
All patients with stercoral colitis should be admitted to the hospital for close monitoring and treatment. 4 Joint management with gastroenterology and colorectal surgery from the outset is recommended, particularly for moderate-to-severe cases. 6 Early surgical consultation allows for rapid intervention if medical management fails or complications develop.
Special Consideration: Ischemic Colitis Complication
When stercoral colitis is complicated by ischemic colitis (suggested by elevated lactic acid with CT findings of bowel wall thickening and fat stranding), urgent fecal disimpaction and laxatives are critical to prevent progression to perforation and peritonitis. 5 This represents a "double-edged sword" scenario requiring particularly aggressive intervention.