What is stercoral colitis, its causes, symptoms, and treatment options, particularly in older adults or individuals with a history of constipation, bowel obstruction, or previous abdominal surgery?

What is Stercoral Colitis?

Stercoral colitis is a rare but potentially life-threatening inflammatory condition of the colon caused by impacted fecal material that creates pressure-induced mucosal injury, colonic wall inflammation, and can progress to ulceration, ischemia, perforation, and sepsis. 1, 2

Pathophysiology and Risk Factors

Stercoral colitis develops when accumulated fecaloma (hardened stool mass) causes increased intraluminal pressure in the colon, leading to mucosal injury and subsequent inflammation of the colonic wall. 1, 3

Key risk populations include:

• Elderly or bedbound patients with chronic constipation 1, 4
• Patients with neurologic disorders (dementia, stroke, cerebral palsy) causing altered mental status 3
• Individuals with recent orthopedic surgery or immobilization 5
• Younger patients with comorbidities predisposing to severe constipation 1

The rectosigmoid colon is the most commonly affected site due to its narrower caliber and propensity for fecal stasis. 5

Clinical Presentation

The clinical presentation is often nonspecific and varied, making diagnosis challenging. 1, 4

Common presenting symptoms:

• Abdominal pain and distension 1, 2, 5
• Constipation or absence of bowel movements 2, 5
• Nausea and vomiting 2
• Altered mental status (particularly in elderly or neurologically impaired patients) 3

Critical warning: Patients may present without typical symptoms, requiring high clinical suspicion especially in high-risk populations. 2 The condition can mimic diverticulitis, ischemic colitis, and inflammatory bowel disease, contributing to diagnostic delays. 4

Diagnostic Approach

CT imaging of the abdomen and pelvis is crucial for diagnosis and the most helpful imaging modality. 1, 5

Key CT findings that establish the diagnosis:

• Fecaloma (impacted fecal material) in the colon 1, 5
• Colonic dilatation, particularly in the rectosigmoid region 1, 5
• Focal mural thickening of the colonic wall 1, 5
• Pericolic fat stranding 1, 5
• Free fluid in abdominal/pelvic cavities (may indicate complications) 5

Plain abdominal radiographs may show bowel distention and fecal material but have limited diagnostic accuracy compared to CT. 5

Important caveat: No established diagnostic criteria exist for stercoral colitis to date, making CT findings essential for securing the diagnosis. 1

Treatment Strategy

Treatment depends on disease severity and presence of complications. 1, 2

Conservative Management (Uncomplicated Cases)

Most cases can be managed conservatively with:

• Intravenous fluid resuscitation 2
• Manual disimpaction (digital rectal disimpaction) 1, 2
• Aggressive multimodal bowel regimen including stool softeners, osmotic laxatives, and stimulant laxatives 2, 3
• Colonoscopic fecal disimpaction in refractory cases 3

Surgical Intervention (Complicated Cases)

Immediate surgical consultation is required for:

• Stercoral perforation 1, 2
• Peritonitis 2
• Sepsis 2
• Hemodynamic instability despite resuscitation 6
• CT evidence of perforation or bowel ischemia 6

Antibiotic Therapy

Parenteral antibiotics should be initiated if there is evidence of perforation, peritonitis, or sepsis. 2

Disposition and Prognosis

Hospital admission should be considered for all patients with stercoral colitis. 2 The condition is associated with high morbidity and mortality if not recognized and managed promptly, with complications including bowel perforation carrying particularly high mortality rates. 1, 4

Multidisciplinary collaboration involving emergency medicine, gastroenterology, and surgery is often required given the diagnostic challenges and potential for rapid deterioration. 1

Key Clinical Pitfalls

• Do not dismiss altered mental status in elderly patients with severe constipation - this may be the primary presentation of stercoral colitis rather than typical abdominal symptoms. 3
• Maintain high clinical suspicion in bedbound or neurologically impaired patients even with atypical presentations, as these populations cannot reliably report symptoms. 1, 3
• Do not delay CT imaging when stercoral colitis is suspected - plain radiographs are insufficient for diagnosis and clinical examination is often nonspecific. 1, 5
• Recognize that prompt relief of fecal impaction is essential - delayed treatment allows progression to life-threatening complications including perforation. 5