Non-perforated Stercoral Colitis patients with septic shock have a higher mortality than their perforated counterparts. A case report and review of literature

INTRODUCTION AND IMPORTANCE: Stercoral colitis is an inflammatory condition caused by fecal impaction; it involves the colonic or rectal wall. It occurs most commonly in nursing home patients, chronic opioid users, and patients with mental impairment. CASE PRESENTATION: We present the case of a 36-year-old, obese, African American male with a history of intellectual disability, bipolar disorder, and chronic constipation. Patient presented to the emergency room after an episode of syncope, confusion, 24-hour abdominal pain, nausea, and vomiting. On admission to the ED the patient was found to be in sepsis; within 4 h he developed septic shock. CT scan of the abdomen showed impacted fecal matter in a significantly distended left and sigmoid colon. This was associated with colitis, extensive fat stranding and free fluid, without pneumoperitoneum. The patient was taken to the operating room for exploration where he underwent an extended left colectomy and Hartmann's procedure. Pathology showed acute focal colitis with transmural necrosis. There were no signs of perforation or inflammatory bowel disease. The patient recovered and was discharged home on post-operative day 8. Upon follow up on post-operative day 22, he was doing well. CLINICAL DISCUSSION: This case illustrates a very rare and challenging scenario. Complications of stercoral colitis include: stercoral ulcer, perforation, ischemic colitis, sepsis and death. Peritonitis, sepsis and bowel necrosis without perforation is extremely rare with very few cases reported in the literature. Colectomy with diversion is the mainstay of therapy. CONCLUSION: It is of paramount importance for ED providers and general surgeons to be aware of this condition. It presents a diagnostic challenge and carries an elevated mortality. Elderly patients on chronic opioids and those with mental impairment are at a higher risk.