Continuing Education Activity

Stercoral colitis is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma formation. Fecalomas can lead to focal pressure necrosis and perforation, while colonic distention and increased intraluminal pressure can lead to compromise of the vascular supply and ischemic colitis. This activity outlines the evaluation and treatment of stercoral colitis and highlights the role of the interprofessional team in managing patients with this condition.

Objectives:

• Describe the etiology of stercoral colitis.
• Identify the pathophysiology leading to the development of stercoral colitis.
• Summarize the management of patients with stercoral colitis.
• Review the importance of collaboration and communication among the interprofessional team to enhance the delivery of care for patients affected by stercoral colitis.

Introduction

Stercoral colitis is a rare inflammatory form of colitis that occurs when impacted fecal material leads to distention of the colon and eventually fecaloma formation. Fecalomas can lead to focal pressure necrosis and perforation, while colonic distention and increased intraluminal pressure can lead to compromise of the vascular supply and ischemic colitis.[1] 

Multiple areas of ulceration can present in the colon. The most common locations of ulceration are in the sigmoid colon and the rectum.[2] When complicated by perforation, the mortality rate can be as high as 32% to 60%.[3][1] Stercoral colitis most often occurs in patients with a history of chronic constipation, elderly patients with dementia, nursing home or bedbound patients, and occasionally young patients with psychiatric conditions.[4] Chronic constipation is the biggest risk factor for developing stercoral colitis.[1]

Etiology

Stercoral colitis occurs when chronic constipation leads to fecal impaction, colonic distention and deformation, and the development of masses of dehydrated fecal material called fecalomas. The fecaloma becomes lodged within areas of the colon, most commonly in the rectosigmoid colon. This can lead to areas of ischemic pressure ulceration and eventually, focal ischemic necrosis and colonic perforation.[3]

About 27% of patients develop multiple areas of focal ulceration.[1] Additionally, the massive colonic distension can also cause diffuse compression of colonic vasculature within the bowel wall, leading to edema, inflammation, and ischemia. The feared complications of this disease are perforation and ischemic colitis. The risk factors for developing chronic constipation are multifactorial and include low fiber diet, genetic factors, behavioral factors, pharmaceutical factors, as well as anatomic and physiologic conditions, which affect colonic motility and absorption.[5]

Epidemiology

Stercoral colitis is a rare condition that has been poorly described in the literature. Most cases are seen in elderly patients, bedbound patients secondary to dementia or stroke, patients with chronic opioid use, and occasionally younger patients with psychiatric conditions.[1] Neurologic and psychiatric comorbid disorders may delay the diagnosis of stercoral colitis by preventing optimal history taking and masking physical examination. Therefore, it is important to keep this diagnosis in mind when evaluating these patients. 

Chronic constipation is more common in the elderly, with a prevalence of one-third of adults aged 60 to 110. This is linked to many risk factors, including tooth loss or improperly fitting dentures, lack of proper diet, inadequate fluid intake, decreased amount of physical activity, and increased amount of daily pharmaceuticals taken by elderly patients. Women also experience constipation more frequently than men.[5] 

Children are also often affected by chronic constipation, particularly during specific stages of life. These stages include weaning, toilet training, and transitioning to school. Pediatric patients with a history of constipation are also at risk of developing stercoral colitis.[6][7]

Pathophysiology

Stercoral colitis occurs when a patient has chronic constipation leading to stagnation of fecal matter. This leads to an increase in volume, impaction, and eventual deformation of the colon. Fecaloma consists of hardened fecal material form, which becomes lodged in certain colonic areas. Focal compression on the colonic wall and vasculature by fecalomas can lead to decreased blood flow to the area. When blood supply does not meet cellular metabolic demand, ulceration, and pressure necrosis of the bowel wall will develop.

Typically, ulceration occurs in areas adjacent to the fecaloma. These ulcerations typically occur on the antimesenteric side of the bowel, likely because the blood supply arises from the mesentery, making the antimesenteric side more vulnerable to ischemia.[1] If not promptly treated, focal pressure necrosis can result in bowel perforation, which carries a high risk of mortality.

Seventy-seven percent of the stercoral ulcerations are found in the sigmoid colon or the rectum. This is because stool in the rectosigmoid colon has decreased water content and is present in the narrowest portion of the colon. Less commonly, bowel dilation can compress the vasculature of an entire segment of the affected bowel. This can lead to diffuse compression of veins and decrease outward blood flow, eventually leading to intramural edema, arterial compromise, and ischemic colitis. Colon involvement of more than 40 cm and intestinal perforation are the biggest predictors of mortality.

History and Physical

Patients with stercoral colitis typically have a history of chronic constipation. Constipation can occur secondary to a neurologic, psychiatric, or metabolic condition (diabetic neuropathy).[3][8] The patient population that is at risk for developing stercoral colitis such as the elderly and the demented can cause limitations when obtaining a history and physical exam, and that is why it is necessary to have a high index of suspicion when evaluating these patients. Symptoms of stercoral colitis include abdominal discomfort, cramps, and fever.

On exam, patients typically have diffuse abdominal tenderness to palpation and abdominal distension. In contrast to intestinal obstruction, patients with stercoral colitis will usually have stool present in the rectal vault on the digital rectal exam and may report passing small volume of stool. In severe cases, patients can present with peritonitis, septic shock, or multiorgan failure if perforation or colonic ischemia have already occurred.

Evaluation

Lab values found in stercoral colitis are non-specific but include leukocytosis and elevated acute phase reactants. Elevated lactic acid and anion gap metabolic acidosis in the setting of stercoral colitis should raise concern for bowel ischemia or perforation.[3] Patients can develop sepsis and septic shock in severe cases, so blood cultures and preoperative labs such as type and screen and coagulation panel should be obtained in addition to basic labs during the initial evaluation of these patients. Because physical exam and lab findings are non-specific, imaging is key in making the diagnosis of stercoral colitis. Patients with peritonitis or suspected perforation should first have an upright chest X-ray to evaluate for free air. The most sensitive and specific study to detect stercoral colitis is CT abdomen and pelvis with IV contrast if the patient’s renal function is adequate.[4]

Findings on CT that suggest the diagnosis of stercoral colitis are fecal impaction with dilation of the colon, most commonly the rectosigmoid colon, but the entire colon can be affected if the patient presents late. Occasionally, fecalomas can be visualized on CT as radiopaque masses within the colon. In cases of edema or ulceration secondary to pressure necrosis, there is a focal thickening of the colonic wall, typically adjacent to fecalomas. There can also be diffuse bowel wall edema from increased intraluminal pressure, which appears as a mucosal discontinuity on CT imaging. Mucosal discontinuity refers to decreased uptake of IV contrast from areas of the bowel wall where blood supply is compromised. This distinguishes stercoral colitis from uncomplicated fecal impaction, where the colonic wall is typically thin. Other findings that suggest stercoral colitis are pericolonic fat stranding.[4]

If extraluminal bubbles of gas or an abscess are visualized, this suggests that perforation has already occurred.[1] The diagnosis can be confirmed with intraoperative findings and histologic studies if surgery is required. In a small study of the imaging findings associated with stercoral colitis, the rectosigmoid colon was involved in 41 of 41 patients, dilation of colon greater than 6 cm and bowel wall thickening greater than 3 mm in the affected colon segment was present in all 41 patients, pericolonic fat stranding was seen in 41/41 patients, mucosal discontinuity was found in 6 of 41 patients, free fluid was observed in 4 of 41 patients, and pericolonic abscess was found in 1 of 41 patients. The findings which mostly related to mortality were perforation and the length of the affected colon segment more than 40 cm.[4]

Treatment / Management

Patients who do not show signs of peritonitis can be managed non-operatively with manual disimpaction via the rectum or with endoscopically guided disimpaction, bowel regimen, and admission for close monitoring.[1][3] Additionally, patients should be kept NPO in case surgical management becomes indicated. Pain control with opioids should be avoided as they decrease colonic motility. Patients with signs of sepsis or septic shock should be resuscitated as needed with IV fluids and broad-spectrum IV antibiotics that cover for gram-negative and anaerobic organisms. Operative management is reserved for patients with perforation, patients who have large segments of bowel involvement, or if conservative management fails. Treatment for these patients involves resection of the affected bowel, colostomy, and Hartmann pouch. Limited surgeries may be associated with inferior clinical outcomes since the residual affected colonic segments carry the risk of recurrent perforations.[1]

Management of constipation involves dietary changes such as increasing fiber, fruit, and fluid intake. Patients with fecal impaction or stercoral colitis should be educated regarding a proper diet and should also be given pharmacologic therapy to prevent constipation in the future. Osmotic and stimulant laxatives are considered first-line treatment for patients with constipation.[9]

Differential Diagnosis

• Diverticulitis
• Large bowel obstruction 
• Ulcerative colitis
• Infectious colitis
• Malignancy
• Bowel perforation
• Acute mesenteric ischemia
• Intra-abdominal abscess

Prognosis

The prognosis of this condition is highly dependent on prompt diagnosis and management. The biggest predictors of mortality are perforation (32% to 59% mortality), a large segment of affected bowel (>40 cm), and ischemic bowel, which is indicated by an elevated lactic acid, or septic shock. There has been no documented significant difference between the age or sex of the patient and mortality.[3] However, this could be because stercoral colitis is under-recognized in the medical community and scarcely documented in the medical literature.

Complications

The most common serious complication of stercoral colitis is a perforation, which is considered as a significant predictor of mortality. Other complications to be aware of are sepsis and septic shock, ischemic colitis, as well as urinary retention secondary to compression by dilated bowel.[3] Multiorgan failure can result secondary to sepsis and hypoperfusion. Renal failure can occur secondary to extrinsic compression and obstruction of ureters. Patients who are managed non-operatively can have a recurrence of ulcerations and resulting perforation in the segments of the colon that were affected. Patients who are managed operatively can develop leakage of anastomosis and resulting sepsis.[3]

Postoperative and Rehabilitation Care

Patients with this condition should be admitted and managed based on their clinical presentation. If the patient is managed non-operatively, they should be monitored with serial abdominal exams, trending labs (WBC, lactic acid, acute phase reactants), and repeat imaging to rule out the need for operative management. Patients with stercoral colitis and concomitant perforation should have emergent surgery to remove the affected colon. These patients have a very high risk of mortality and should be monitored postoperatively in the intensive monitoring unit.[3]

Deterrence and Patient Education

Patients with chronic constipation should be educated regarding dietary habits to increase the frequency of bowel movements to prevent complications such as stercoral colitis. In patients who do not respond to lifestyle modifications alone, laxatives and other pharmacologic interventions should be considered. Patients who develop complications from chronic constipation such as fecal impaction or stercoral colitis should have regular follow up with a dietician and gastroenterologist. Studies such as colonoscopy, anorectal manometry, barium study, and colonic transit can be used to identify secondary causes of constipation. A review of home medications can also be useful to identify any pharmacologic causes of constipation.[5]

Pearls and Other Issues

The diagnosis of stercoral colitis requires a high index of suspicion as it mimics other common intra-abdominal pathologies.Prompt recognition and proper management of this condition are crucial to prevent colonic perforation, ischemic colitis, sepsis, and subsequent morbidity and mortality.[1]

Management is primarily determined by the presence or absence of sepsis, bowel ischemia, or bowel perforation.[3]

Enhancing Healthcare Team Outcomes

Stercoral colitis is an uncommon disease that is relatively under-documented; therefore, medical professionals should become educated on the signs, symptoms, and management of this condition. These patients often require an interprofessional group of physicians, including an internist, surgeon, gastroenterologist, pharmacist, infectious disease specialist, radiologist, intensivist, and dietitian. A surgical consult should be placed early. The patient's disposition is largely determined by their clinical presentation, and even patients that are initially stable should be monitored closely, given the high fatality associated with complications of this disease.

Blood cultures and sensitivity profiles should be monitored, and antibiotics adjusted accordingly. Infectious disease consult may be beneficial in some cases. Patients should be closely monitored after intervention as complications of operative and non-operative management carry a high risk of mortality.

There should be an investigation into the cause of impaction that led to this condition. If the patient suffered from chronic constipation, which led to the development of stercoral colitis, a bowel regimen should be started, and outpatient gastroenterology follow-up arranged upon discharge to prevent disease recurrence. If other factors led to the development of this condition, such as neuropsychiatric disorders or opioid use, these issues should be addressed with social services, psychiatry, or pain management to optimize them for safe discharge.

This is a rare and complex disease that carries high morbidity and mortality and therefore requires communication between a team of interprofessional physicians, nurses, dieticians, and social workers to optimize outcomes.[10] [Level 3]