Stercoral colitis

Background

Normal inner diameters of colon sections.

• Inflammatory colitis related to increased intraluminal pressure from impacted fecal material in the colon
  • Pressure from fecaloma or colonic distention may cause ulceration/necrosis and ultimately perforation
• Rare condition, but with high mortality rate (32-59%) when complicated by perforation
• Primarily in elderly, nursing home, or young patients with neurological impairment, chronic opioid use

Clinical Features

• History of chronic constipation and/or fecal impaction
• May be asymptomatic or have only mild abdominal pain at initial stages
  • Maintain a high index of suspicion; a recent review shows lack of abdominal pain in as much as 62% of cases
• Abdominal pain/tenderness, distension, vomiting are most common symptoms
• Rectal bleeding
• Symptoms and signs of peritonitis or shock

Differential Diagnosis

Constipation

• Behavioral-related
  • Lack of exercise
  • Diet-related
• Fecal impaction
  • Stercoral colitis
• Ileus from surgical abdomen
  • Appendicitis
  • Diverticulitis
• Bowel obstruction
  • Small bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Malignant bowel obstruction
  • Specific causes: tumor, stricture, hernia, adhesion, volvulus
• Painful anorectal disorders (e.g. anal fissure, hemorrhoids)
• Medical causes
  • Hypothyroidism
  • Electrolytes
    • Hypomagnesia
    • Hypercalcemia
  • Hypokalemia
• Medication-related
  • Opiods, antipsychotics, anticholinergics, antacid, antihistamines
• Constipation (peds)

Evaluation

Abdominal CT showing stercoral colitis with preformation (free air shown by arrows).

Work up

• Digital rectal exam
• Abdominal panel
  • CBC
  • Chemistry (hypokalemia or hypercalcemia)
  • LFTs + lipase
  • Consider coagulation studies (PT, PTT, INR), as a marker of liver function
• Lactate
• Consider preoperative labs including type & screen
• Consider TSH if concern for hypothyroid related constipation
• CT abdomen/pelvis with IV contrast
  • CT findings with focal thickening of colonic wall, stranding of pericolonic fat in segment showing fecal impaction, and presence of extraluminal bubbles of gas or abscess
  • Fecolomas may be visualized as radiopaque masses

Diagnosis

• Diagnosis is typically made on CT

Management

• Fluid resuscitation
• Broad spectrum antibiotics covering intra-abdominal flora (e.g., ceftriaxone + metronidazole)
• Surgical consult, NPO
  • May ultimately be treated nonsurgically (e.g. manual disimpaction, enemas), if no evidence of bowel perforation or ischemia

Disposition

• Admit

See Also

• Fecal impaction