A Case of Stercoral Colitis Causing Bladder Inflammation and Hematuria in a 29-year-old Man With Cerebral Palsy

Abstract

Introduction: Stercoral colitis is a rare and potentially fatal complication of chronic constipation. In the setting of constipation, a large stool burden, often in the form of a fecalith, impacts the colon causing increased luminal pressure, decreased blood supply, secondary ischemia, colitis and possibly ulceration and perforation. There are about 200 reported cases of stercoral colitis in the literature but currently no reports of this condition presenting with hematuria. Case Report: A 29-year old man with a history of cerebral palsy with contractures requiring an intrathecal baclofen pump presented with constipation and frank hematuria. Prior to presentation, his family noted hard stools and abdominal discomfort. An episode of hematuria then prompted them to bring him to the emergency room. His examination was notable for tachycardia, dry mucus membranes and a soft, non-distended abdomen, hypoactive bowel sounds and diffuse abdominal tenderness. A foley catheter was placed and frankly bloody urine was noted. Initial laboratory values were notable for a leukocytosis of 18 k/uL, hemoglobin of 17.7 g/dL, normal coagulation factors and a urinalysis significant for large blood. Microscopy confirmed many red blood cells, no bacteria and had a negative culture. A CT-abdomen was obtained and revealed stool in the rectal vault with rectal wall thickening and perirectal inflammation, suggestive of stercoral colitis as well as circumferential bladder wall thickening adjacent to the area of colitis (images). He was started on treatment with IV fluids, empiric piperacillin/tazobactam, manual disimpaction and aggressive oral bowel regimen. Urology was consulted and felt that the most likely etiology of his hematuria was inflammation secondary to the stercoral colitis. Following two days of treatment he had multiple bowel movements and his abdominal discomfort and frank hematuria resolved. Discussion: Stercoral colitis is a potentially dangerous complication of chronic constipation and therefore it is important to understand its presentations. This case demonstrates that stercoral colitis can cause bladder inflammation and hematuria and that this may in fact be the presenting complaint. The variability of presentation of stercoral colitis is particularly important in patients with impaired cognition who may not report classic symptoms like constipation. We therefore recommend aggressive pursuit of cross-sectional imaging in patients at risk for this condition.Figure: Axial image from non-contrast CT abdomen/pelvis showing stercoral colitis and bladder wall thickening.Figure: Coronal image from non-contrast CT abdomen/pelvis showing stercoral colitis and bladder wall thickening.Figure: Sagittal image from non-contrast CT abdomen/pelvis showing stercoral colitis and bladder wall thickening.