Rare but relevant: a systematic review of stercoral perforation

Stercoral Colitis: Review of Imaging Features and Complications

Stercoral colitis is an inflammatory reaction secondary to fecal impaction and almost always occurs in the setting of chronic constipation. Luminal distention caused by dense and dehydrated stool compresses the vascular supply of the distal colon, resulting in bowel ischemia and ulceration. Stercoral colitis primarily affects elderly patients, but it can be seen in any patient with decreased bowel motility, with risk factors including neurodegenerative disorders, chronic medical diseases, malignancy, immobility, and the use of narcotic or anticholinergic medications. Patients most often present with abdominal pain and tenderness. However, the presentation is often nonspecific and can include nongastrointestinal symptoms. Due to the common presence of comorbidities, a thorough history and physical examination findings may be difficult to obtain. Imaging, especially CT, plays a vital role in the diagnosis of stercoral colitis, demonstrating hallmark features such as fecal impaction and a large colorectal stool burden. Mural thickening (>3 mm) and other CT signs of inflammation aid in diagnosis, although findings including perirectal fat stranding can be nonspecific. Signs of perforation, including mural discontinuity, extraluminal air, and extraluminal stool collections, can also be identified. Other potential complications include obstruction, bleeding, fistulas, and urinary tract involvement secondary to mass effect. The overlap of findings between stercoral colitis and other colonic diseases, particularly diverticulitis and malignancy, can sometimes make diagnosis challenging. Identification of fecal impaction and associated inflammatory changes helps in distinguishing stercoral colitis from other pathologic conditions. Prompt diagnosis of stercoral colitis and its complications allows appropriate management, which can range from preventive measures to emergent surgical treatment. ©RSNA, 2025 Supplemental material is available for this article.

Acute Constipation and A Stercoral Perforation: A Case Report

Stercoral perforation typically arises as a sequela of chronic constipation and can lead to bowel perforation due to fecal impaction. While uncommon, maintaining a high clinical suspicion in the appropriate setting is crucial. We present a case report involving a 52-year-old female with no history of chronic constipation, who presented with an unexplained large bowel obstruction. Subsequent extensive diagnostic workup revealed stercoral perforation, necessitating diagnostic laparoscopy and sigmoidectomy. This case underscores that while stercoral perforation can be life-threatening, clinical stability permits the use of minimally invasive techniques without compromising patient safety or health.

Stercoral Colitis Secondary to Opiate-Induced Constipation

The authors present the case of a 62-year-old woman who had stercoral colitis secondary to opiate use for rheumatoid arthritis leading to chronic constipation. Computed tomography imaging demonstrated stool along a significant length of the colon. Stercoral colitis is a seldom suspected cause of severe abdominal pain. Although constipation may seem benign, when it gets to the level of a stercoral colitis, mortality due to colonic perforation is a very real concern. The authors review the presentation, risk factors, and management of stercoral colitis.

Stercoral colitis: CT imaging findings and clinical risk factors

PURPOSE

To describe and update stercoral colitis clinical risk factors, relative frequency, location, and CT imaging features correlated with surgical and pathological results.

METHODS

CT reports over a 5-year period (05/2017-05/2022) at a single medical center were searched. Main inclusion criteria were luminal distention with formed stool, wall thickening, and surrounding inflammation. Positive cases were graded as mild (early or developing stercoral colitis) versus moderate-to-severe based on CT findings. Medical records were reviewed for risk factors and outcome data in moderate-to-severe cases. P-values were tabulated for comparison.

RESULTS

545 total cases (71 (60, 82) years, 278 males) were identified on CT, including 452 mild (82.9%) and 93 moderate-to-severe cases (17%, 67 (55, 79) years, 48 females). Twenty cases showed evidence of perforation (3.7% total cohort, 22% moderate-to-severe cohort). Diagnosis as an incidental finding was frequent (46.0% of mild cases). Most cases involved the rectum (97.6% of mild cohort and 69% of moderate-to-severe cohort). The sigmoid was involved in 31% of moderate-to-severe cases, but 95% of the perforated subcohort (19/20, 13/20 without rectal involvement). Among the moderate-to-severe cohort, perforation was associated with slightly increased wall thickness (6.4 vs. 5.7 mm, p = 0.03), opioid use (50 vs. 23%, p = 0.04), and disease-specific mortality (11 vs. 0%, p =0.04). Perforation was less associated with major neurocognitive disorders (20 vs. 60%, p = 0.003), institutionalized status (5 vs. 38%, p = 0.005), and a prescribed bowel regimen (30 vs. 63%, p = 0.01).

CONCLUSION

Stercoral colitis may be under-reported. Perforation tends to favor sigmoid involvement and a less traditional patient cohort.

Stercoral Colitis in the Emergency Department: A Retrospective Review of Presentation, Management, and Outcomes

STUDY OBJECTIVE

Stercoral colitis is inflammation of the bowel wall caused by fecal impaction. Despite reported high morbidity and risk of perforation, little research assessing outcomes is available. This study characterizes the presentation, management, and outcomes of emergency department patients with stercoral colitis.

METHODS

We performed a retrospective chart review of ED patients with stercoral colitis identified on computed tomography (CT) scan. Of 814, 522 visits to multiple EDs across the US, 269 met the inclusion criteria. Variables regarding patient presentation, management, and outcomes were extracted from electronic medical records. Results were analyzed with percentages and 95% confidence intervals (CIs).

RESULTS

Of 269 patients, the median age was 76 years. The most common chief concern was abdominal pain/distension (33.8%). However, abdominal pain was documented as absent in 62.1% of cases. The most common CT findings included fecal impaction (96.7%), bowel wall inflammation (72.9%), and fat stranding (48.3%). Eighty-four (31.2%) patients were discharged home from the ED, and over half of these (45/84, 53.6%) received no enema, laxatives, or disimpaction. Overall, 9 patients (3.3%, 95% CI 1.6% to 6.5%) required surgical management of a related complication within 3 months, 27 (10.0%, 95% CI 6.8% to 14.4%) returned to the ED within 72 hours, and 9 (3.3%, 95% CI 1.6% to 6.5%) died from a cause related to stercoral colitis within 3 months.

CONCLUSION

Patients with stercoral colitis often present in a nonspecific manner, and short-term mortality is substantial. In this study, most discharged patients did not receive recommended treatment. This represents the largest ED study of stercoral colitis and provides further evidence linking this diagnosis with adverse outcomes.

Small Bowel Evisceration Through a Perforated Stercoral Ulcer

Stercoral ulcers are localized areas of loss of colonic mucosal integrity. They result from pressure necrosis of the colonic mucosa, secondary to chronic constipation and fecal inspissation. These ulcers are rare and, are associated with serious complications, including bleeding and perforation. We present the case of a 50-year-old woman who presented with small bowel evisceration through the anal canal secondary to extraperitoneal perforation of the rectum. The patient underwent emergent exploratory laparotomy with reduction of the bowel, followed by second look laparotomy in 24 hours. A full thickness defect in the rectum was identified and Hartmann's procedure was performed. The patient's postoperative course was uneventful. Extraperitoneal perforation and evisceration of bowel is a rare clinical entity. These cases are diagnosed early due to the obvious clinical presentation and however may be misdiagnosed as prolapse. They necessitate urgent and careful surgical planning, to ensure preservation of bowel and complete recovery.

Rare Presentation of Stercoral Ulcer Spontaneous Perforation Without Preceding Radiographic Evidence of Colonic Inflammation and Fecal Impaction

Stercoral ulcers are caused by persistent fecal impaction. A life-threatening consequence of stercoral ulcers is colonic perforation, which is rare. A high index of clinical suspicion should be held for patients with stercoral ulcer, as colonic perforation is a medical emergency, requiring immediate surgical intervention. Here, we report a case of a 45-year-old female admitted with sepsis of unknown picture and subsequently developed stercoral ulcer perforation (SUP), diagnosed intraoperatively, without prior radiographic evidence of colonic inflammation. She was successfully managed with emergency laparotomy and left colectomy with sigmoid colectomy.