Early Diagnosis and Treatment of Stercoral Colitis With an Aggressive Bowel Regimen

Abstract

Introduction: Stercoral colitis is a rare inflammatory colitis which results from fecal impaction causing increased colonic intraluminal pressure, which may progress to ischemic necrosis, ulcer formation, and colonic perforation. The majority of cases continue to be reported in the surgical literature with late complications of bowel perforation requiring surgical intervention, which is associated with a 35% mortality rate. We present a patient with acute symptoms of increased bowel urgency and frequency who was diagnosed with stercoral colitis and successfully treated with an aggressive bowel regimen, thus avoiding surgery. Case Report: A 92-year-old female with a history of chronic constipation presented with frequent diarrhea associated with pain, pressure, and small blood streaks for a period of 1 week. She had previously discontinued her anticonstipation bowel regimen and was taking Norco after sustaining a fall 3 weeks prior to admission. Abdominal radiograph revealed a large fecal ball in the rectosigmoid colon and CT abdomen showed stercoral colitis with impaction, dilation of the proximal sigmoid colon, and marked rectal wall thickening. Manual disimpaction was unsuccessful and an aggressive bowel regimen consisting of fleet’s enemas, magnesium citrate, mineral oil enema, and oral mineral oil was initiated. After 4 days of treatment there was clinical and radiographic evidence of resolution. Discussion: Stercoral colitis can be fatal and requires prompt treatment. The importance of early recognition is underscored by the high mortality rate associated with late complications reported in the surgical literature. Early diagnosis with CT imaging demonstrates a fecaloma, focal wall thickening of a dilated sigmoid colon and rectum representing edema from ischemia or ulceration, and peri-colonic or peri-rectal fat stranding. The most common site of impaction occurs in the sigmoid and rectosigmoid colon, which, in addition to having a relatively poor blood supply, have the narrowest colonic diameter allowing for higher intraluminal pressure. Ischemic pressure necrosis results when luminal distention increases pressure above bowel wall capillary perfusion pressure. Ulcerations are seen in up to 27% of cases, with 77% occurring in the sigmoid and rectosigmoid colon. The best way to prevent stercoral colitis is to prevent constipation, which is present in approximately 60% of patients with fecal impaction. Early diagnosis of fecal impaction should prompt aggressive bowel cleansing and manual disimpaction, which may reduce pressure and decrease the risk of ulceration.