emDOCs Podcast – Episode 140: Stercoral Colitis

What is stercoral colitis?

• Stercoral colitis is an inflammatory condition of the large bowel.
• Caused by longstanding constipation with substantial stool burden; leads to high intraluminal pressures and colonic distension.
• Most common area is the sigmoid colon, the antimesenteric border of the rectosigmoid junction, and the anterior rectum.
  • These areas exhibit decreased perfusion in watershed areas, smaller luminal diameters, and lower stool water content.
• High pressures and intraluminal distension cause vascular compression of bowel wall; if untreated, progresses to bowel ulceration, focal bowel ischemia, bowel wall perforation, peritonitis, sepsis, and death.

How common is this?

• True prevalence and incidence not well understood; likely uncommon overall.
• 2023 retrospective chart review of all ED encounters at 21 U.S. hospitals over a 29-month period identified that the words “stercoral colitis” appeared in the impressions of 0.008% of all CT abd/pelvis in patients > 65 years and 0.003% of CT impressions regardless of age.
  • Median age of diagnosis was 76 years with a range of 6 to 98 years [1].
• Another study found 3.2% of all bowel perforations were due to stercoral colitis over 5 years.
• Mortality rates range between 32-60% if perforation occurs with stercoral colitis [7-8].

What are the major risk factors?

• Major risk factors are chronic constipation and older age.
• Chronic constipation affects over one third of patients over 60 years, with females more commonly affected [9].
• Other common risk factors include poor diet, immobility and/or sedentary lifestyle, nursing home or long care facility resident, dementia, psychiatric conditions, and medication side effects (in particular opioids, but many others).

How do these patients present?

• Variable presentation, with no pathognomonic constellation of symptoms.
• Common symptoms: abdominal pain and cramping, abdominal distention, constipation, rectal pain, nausea, and vomiting.
  • Less common symptoms: general weakness, altered mental status, problems with urination, and gastrointestinal hemorrhage
• Exam: abdominal tenderness to palpation, tenderness and impacted stool on digital rectal examination. Peritonitis, abnormal vital signs/hemodynamic instability may be present with perforation.
• Literature suggests many patients will not present with the classic presentation:
  • 39% of patients report a chronic history of constipation [3].
  • 2024 study estimated that of patients with radiographic evidence of stercoral colitis, 62% denied abdominal pain; 22% had a chief complaint not GI related.
  • 2023 chart review reported that 46% of mild cases and 22% of moderate to severe cases lacked common symptoms [5].
  • Patients who are elderly or who have developmental disabilities are more likely to present with unrelated symptoms [14, 24-25].
• Key: Do not rely on the classic picture for diagnosis. Imaging need for further evaluation.

What testing is recommended?

• Diagnosis requires imaging with CT abdomen/pelvis IV contrast.
  • No official diagnostic criteria for CT.
  • Mild cases: impacted stool, fecaloma, colonic dilation.
  • Moderate: colonic dilation >6 cm, colonic wall thickening >3 mm, pericolonic fat stranding.
  • Severe/Perforation: pneumoperitoneum, pneumatosis intestinalis, pericolonic abscess, extraluminal stool, discontinuity in the bowel wall.
• X-ray (abdominal/chest) may reveal free air if perforation occurs.
• Laboratory testing is nonspecific: leukocytosis, elevated acute phase reactants, lactic acidosis, electrolyte abnormalities. Obtain blood cultures if unstable/concern for perforation.

What are the key tenets of management?

• No society guideline recommendations for treatment.
• Goal: resuscitate if necessary; decrease intraluminal pressure with fecaloma removal.
• Manage symptoms with antiemetics, analgesics (avoid opioids if possible), IV fluid resuscitation if dehydration, electrolyte repletion.
• Mild/moderate cases without perforation: consider performing a digital rectal disimpaction followed by bowel enema and oral bowel regimen [15].
  • No specific enema superior in patients with stercoral colitis. In addition, an oral bowel regimen should be started.
  • Oral bowel regimen: combination of osmotic laxatives and stimulant laxatives.

Should we consult the surgeon in all cases of stercoral colitis?

• Consultation is recommended in most (if not all) patients with stercoral colitis.
• Emergent indications for surgical intervention: stercoral perforation, peritonitis, ischemic colitis, gastrointestinal hemorrhage, and failed conservative management [15].
  • These patients need resuscitation (IV fluids and vasopressors), broad spectrum antibiotics that cover Pseudomonas aeruginosa, Enterobacter subspecies, anaerobic bacteria, and Enterococcus subspecies (piperacillin-tazobactam 4.5 g every 6 hours or meropenem 1 g every 8 hours or metronidazole 500 mg every 8 hours plus ampicillin 2 g every 4 hours plus cefepime 2 g every 8 hours).
  • Surgical specialist consultation recommended for extensive bowel involvement (> 40 cm of contiguous involvement associated with increased mortality).

Why involve a surgeon in mild/moderate cases?

• Controversy as to whether patients with uncomplicated cases of stercoral colitis need surgery consultation in the ED.
  • Positives: surgical specialists can perform endoscopic disimpaction and lavage (assist in bowel decompression); endoscopic disimpaction and lavage could be superior to digital disimpaction and medical management.
  • Negatives: Unless direct visualization is required to secure the diagnosis, endoscopic disimpaction and lavage is often unnecessary, technically challenging, and may cause iatrogenic injury.
• Consultation with a surgical specialist is not a substitute for performing a digital rectal disimpaction and initiating medical management while the patient is in the ED.

How should we manage the patient with mild/moderate stercoral colitis?

• Digital disimpaction dislodges impacted stool in the rectum and is recommended in those with no perforation. If perforation or severe inflammation, avoid disimpaction.
• Following disimpaction, administer enema. Enemas draw water into the bowel, directly lubricate the stool, and/or stimulate the large bowel to eliminate stool.
  • Lubricating enemas include those containing mineral oil and soap suds/tap water.
  • Stimulant enema: bisacodyl is a stimulant enema.
  • Combination of osmotic, lubricating, stimulating effects: glycerin and sodium phosphate enemas.
  • There are no guidelines or available data identifying the most superior enema in stercoral colitis.
    • Signals toward harm for sodium phosphate enemas in elderly and pediatric patients being treated for constipation.
•  Start oral bowel regimen:
  • Polyethylene glycol, lactulose, magnesium hydroxide, magnesium citrate.
    • Inexpensive, readily available oral osmotic laxatives.
    • Polyethylene glycol and lactulose are superior to placebo for constipation.
    • Some experts recommend a full bowel preparation (e.g., those prior to colonoscopy) as first line oral bowel regimen for stercoral colitis.
  • Bisacodyl, sodium picosulfate, senna are stimulant laxatives: irritate sensory nerve endings in the colon, reduce colonic water absorption.
  • Unless there is dietary fiber deficiency, fiber supplementation not recommended given its mechanism as a bulking agent (does not improve colonic motility).

• PAMORAs (Peripherally acting μ-opioid receptor antagonists): medication class for patients with stercoral colitis induced by opioid use.
  • Maldemedine, naloxegol, methylnaltrexone.
  • American Gastroenterological Association recommends treatment of opioid induced constipation with conventional laxatives first, but guidelines recommend that PAMORAs be considered in cases of laxative-refractory opioid-induced constipation, defined as moderate to severe symptoms of constipation despite the use of laxatives from 1 or more laxative classes for at least 4 days over a 2 week period.
    • If present, naldemedine or naloxegol is strongly recommended, but methylnaltrexone has a conditional recommendation.
    • Naldemedine and naloxegol are available in oral formulations; methylnaltrexone is available in oral and subcutaneous formulations.
  • Cost may limit availability.

Can patients with mild to moderate stercoral colitis be safely discharged from the ED?

• No evidence-based guidelines for disposition of patients diagnosed with stercoral colitis in the ED with immediate indication for surgical intervention [1-2].
• Also no current clinical decision tools to assist in determining disposition.
• Patients not requiring emergent surgical evaluation require aggressive medical management to prevent disease progression with multimodal bowel regimen, dietary changes.
• Repeat clinical assessment and monitoring of the quantity and consistency of bowel movements also necessary.
• Patients can experience electrolyte imbalances due to medical therapies for stercoral colitis.
• Due to these factors, combined with the high associated short term morbidity and mortality, inpatient admission likely beneficial.

What is the prognosis for patients diagnosed with stercoral colitis?

• High risk of short-term morbidity and mortality due to complications: ischemic colitis, stercoral perforation, intra-abdominal abscess, peritonitis, urinary retention, ureteral compression, and sepsis.
  • Key complications associated with increased mortality: ischemic colitis (35%), perforation (35%), perforation with septic shock (60%).
  • Patients with > 40 cm of involvement have mortality rate of 57.1%.
• Rare complications: lower GI hemorrhage; small bowel evisceration through stercoral perforation; infection or abscess of the musculature of the back, spine, epidural space.
• Complications needing urgent surgical intervention: abdominopelvic abscess, rectal stump leak, and interval re-development of stercoral colitis and perforation of the remaining bowel.
• 2023 retrospective chart review of stercoral colitis found 3.3% died of a complication from stercoral colitis within 3 months; all-cause mortality was 7.8%, 12.3%, and 19.8% at 1 month, 3 months, and 12 months, respectively [1]. Median days from ED diagnosis to death was 152, 76, and 81 for patients discharged from the ED, admitted to the hospital, and overall, respectively.

What are the takeaways?

• Stercoral colitis is an inflammatory condition of the large bowel associated with constipation and fecal impaction leading to increased intraluminal pressure, necrosis, ulceration, and even perforation of the colon
• Variety of ways it can present, but most commonly patients have abdominal pain and constipation
• Major risk factors are older age, constipation, bed-bound, and chronically ill patients.
• CT abd/pelvis with IV contrast recommended for diagnosis.
• Treatment goals are resuscitation if needed and intraluminal decompression.
• For mild to moderate stercoral colitis perform digital rectal disimpaction, followed by enema and oral bowel regimen.
• Surgery consultation with admission is likely helpful in all patients because of the complications and need for monitoring.
• Patients with severe complications like perforation need IV antibiotics, resuscitation, and operative intervention.

References:

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