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A CASE OF SEVERE STERCORAL COLITIS COMPLICATED BY ISCHEMIC BOWEL AND SEPTIC SHOCK
Maher Taha
*1, Lana Dardari
2, Arthur C. Igbo
1, Rodwan Jomaa
1, Karina Gomez
1, Elizabeth Chandy
1, Jay Yepuri
1,3,41Internal Medicine, Texas Health Resources, Arlington, TX; 2Cleveland Clinic, Cleveland, OH; 3American College of Gastroenterology, Bethesda, MD; 4American Gastroenterological Association, Bethesda, MD
Stercoral colitis is a rare inflammatory colitis where impacted fecal material leads to colon distention and fecaloma formation. It can lead to necrosis, perforation, and/or sepsis, with a mortality rate up to 63% when complications arise. It 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.
A 33-year-old male with a history of bipolar I disorder, schizoaffective disorder, and chronic marijuana use presented to the ED with vomiting, diarrhea (preceded by chronic constipation), and abdominal pain. The patient mentions he had a similar episode 10 years prior where he required a colonoscopy. He had diffuse abdominal tenderness and distention and he rapidly progressed to septic shock.
Notable findings included: WBC 19.8, lactic acid 6.98, and procalcitonin 10.83. CT revealed severe colonic distention with fecal impaction from the transverse colon to the rectum, without bowel obstruction or perforation.
In the ICU he required IV fluids and vasopressors, antibiotics and a bowel regimen. Digital disimpaction failed. Due to concern for bowel ischemia, the patient underwent emergent colonoscopy, revealing extensive stool burden and bowel ischemia. Complete disimpaction was unsuccessful and surgical exploration was recommended. The patient underwent exploratory laparotomy which revealed a gangrenous sigmoid colon with stercoral obstruction. A partial colectomy with descending colostomy was performed. Postoperatively, the patient progressed to oral intake after colostomy output was established. His shock resolved and he was discharged with significant improvement and resolution of symptoms.
Stercoral colitis is a rare condition that is not well-characterized in literature. Patients often have a history of chronic constipation. Unlike intestinal obstruction, patients with typically have stool in the rectal vault on digital rectal examination and may pass stool. The most sensitive and specific study to detect stercoral colitis is CT abdomen and pelvis with IV contrast. Conservative management includes digital or endoscopic disimpaction, and an aggressive bowel regimen. Operative management is for patients with perforation, large segments of bowel involvement, or if conservative management fails. Patients should be advised on dietary adjustments for constipation to risks such as stercoral colitis. For individuals who do not improve with lifestyle changes, the use of laxatives and other pharmacological treatments should be considered. Diagnosis requires a high level of clinical suspicion. Early recognition and appropriate management are essential to prevent complications which are associated with higher morbidity and mortality. Treatment strategies are guided by the presence or absence of associated complications.
Image A: Coronal CT imaging of abdomen and pelvis revealing colonic distention and significant intraluminal stool burden
Image B: Resected sigmoid and descending colon showing significant distention and focal pressure necrosis.
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