What is the recommended treatment for an older adult with a history of constipation or fecal impaction diagnosed with stercoral colitis?

Treatment of Stercoral Colitis in Older Adults

In older adults with stercoral colitis, immediate treatment depends on disease severity: uncomplicated cases require urgent manual disimpaction followed by polyethylene glycol (PEG) lavage and maintenance laxatives, while complicated cases with perforation, peritonitis, or septic shock mandate emergency surgical resection with diversion. 1, 2, 3

Initial Assessment and Risk Stratification

Obtain CT imaging immediately to confirm diagnosis and identify complications including bowel wall thickening, fecaloma, colonic dilatation, fat stranding, free air, or perforation. 2, 4 The presence of sepsis, peritonitis, or perforation fundamentally changes management from medical to surgical. 3, 4

Key laboratory findings to assess severity:

• Leukocytosis and elevated lactate suggest bowel ischemia or necrosis, even without perforation. 3, 5
• Check complete blood count, electrolytes, renal function, and albumin levels. 1

Medical Management for Uncomplicated Cases

For patients without perforation, peritonitis, or septic shock, proceed with aggressive bowel decompression:

Immediate Disimpaction Protocol

• Perform digital fragmentation and manual extraction of impacted stool as first-line intervention. 1
• Follow with water or oil retention enemas to facilitate passage through the anal canal. 1
• Once distal colon is partially cleared, administer oral PEG solutions with electrolytes to soften and wash out remaining stool. 1, 6

Antibiotic Considerations

• Initiate broad-spectrum IV antibiotics if there are signs of colonic wall inflammation, fat stranding, or systemic inflammatory response, as stercoral colitis can progress to ischemic colitis and sepsis. 2, 3, 4
• The inflammatory process from fecal impaction causes mucosal injury that may become secondarily infected. 7, 2

Supportive Care

• Provide aggressive IV fluid resuscitation to correct dehydration and electrolyte imbalances common in severe constipation. 1, 4
• Discontinue all constipating medications including opioids, anticholinergics, and calcium channel blockers when possible. 1

Surgical Management for Complicated Cases

Emergency surgery is mandatory for:

• Perforation with pneumoperitoneum or peritonitis 3, 4
• Septic shock or hemodynamic instability 3, 4
• Bowel necrosis or transmural ischemia 3, 5
• Failure of conservative management with clinical deterioration 2, 4

The surgical procedure of choice is extended left colectomy or sigmoid colectomy with Hartmann's procedure (end colostomy with rectal stump). 3 Primary anastomosis should be avoided in the setting of fecal contamination, inflammation, and compromised bowel. 3

Critical Clinical Pitfalls

Non-perforated stercoral colitis with septic shock carries higher mortality than perforated cases, likely due to delayed recognition and extensive bowel necrosis. 3 Do not assume absence of free air means conservative management is safe if the patient is septic.

Stercoral colitis mimics other conditions including diverticulitis, ischemic colitis, and inflammatory bowel disease, leading to diagnostic delays. 7, 2 Maintain high suspicion in elderly patients with chronic constipation presenting with acute abdominal pain.

Lactic acidosis indicates bowel wall ischemia and should prompt urgent intervention even without perforation. 5 This represents impending necrosis requiring either aggressive medical management or surgical consultation.

Post-Acute Prevention Strategy

After successful treatment, implement a rigorous maintenance bowel regimen:

• Prescribe daily osmotic laxatives (PEG) or stimulant laxatives to prevent recurrence. 1
• Avoid bulk-forming laxatives as these can worsen impaction in patients with motility disorders. 1
• Ensure adequate hydration and dietary fiber intake as lifestyle modifications. 6
• Regular monitoring and early intervention for constipation symptoms to prevent progression. 1

Special Considerations in Elderly Patients

Older adults are at highest risk due to age-related enteric nervous system degeneration, polypharmacy, reduced mobility, and comorbidities. 1, 7

Nursing home residents and patients with cognitive impairment may not report symptoms until advanced disease develops. 3, 4 These populations require proactive bowel management protocols.

Hospital admission is indicated for all patients with stercoral colitis given the high risk of complications and need for close monitoring. 4