Background & Pathophysiology:

  • An inflammatory colitis caused by fecal impaction
  • Marked distension and increased intraluminal pressure leads to ischemic pressure necrosis of the colonic wall and compromise of vascular supply and mucosal perfusion
  • Risk of progression to colonic perforation and peritonitis
  • Multiple areas of ulceration occur adjacent to the fecaloma; most commonly in the rectosigmoid colon


  • Lab findings are non-specific – may reveal increased WBC and/or acute phase reactants
  • Increased lactate and anion gap metabolic acidosis should raise concern for ischemia and/or perforation
  • Supine and erect chest & abdominal radiographs are needed to eval for intraperitoneal free air under the diaphragm, dilated loops of bowel, and air-fluid levels
  • CTAP with IV contrast will reveal dilation of the sigmoid colon, colonic wall thickening, thickened rectum, presence of fecal impaction/fecaloma, and/or pericolonic fat stranding
  • If extraluminal bubbles of gas or abscess are visualized, this suggests perforation has already occurred.

Clinical Presentation:

  • Typically elderly patients with chronic constipation; especially those with dementia, nursing home, or bedbound
  • Younger patients with psychiatric conditions, patients with chronic opioid use, pediatric patients with severe constipation are also be at risk
  • Can present sub-acutely with complaints of constipation (acute on chronic), generalized or localized (LLQ) abdominal pain, urinary retention
  • Patients who have perforation may present in extremis with signs of peritonitis and sepsis


  • Joint management with gastroenterology and surgical services
  • Stable patients may undergo aggressive bowel regimen with laxatives, enemas, and disimpaction
  • GI Endoscopically guided disimpaction may be necessary
  • Operative indications: perforation, large segments of bowel involvement, or failure of conservative management
  • If fecal impaction is not relieved, colonic perforation with peritonitis and decompensation can occur.
    • Treat aggressively with IVF, antibiotics (covering gram negative and anaerobic organisms), and rapid transfer to the OR to resect the affected colon
  • A 32-60% mortality rate has been reported when stercoral colitis is associated with perforation!
  • Patients with stercoral colitis should be admitted for decompression of the bowel and close monitoring


  • Stercoral colitis is an uncommon but potentially fatal complication of chronic constipation
  • A high index of suspicion is necessary and should be considered in all patients who present with abdominal pain and constipation, particularly in the elderly
  • Active co-management and care coordination with medicine, gastroenterology, and general surgery
  • While conservative treatment with bowel regimens and disimpaction may prevent progression, there is a significant potential for perforation
  • Imaging: CTAP is the modality of choice for diagnosis
  • If starting with plain radiographs, supine & erect films or decubitus are needed to evaluate for free air (multi-view supine x-rays are inadequate) – ensure appropriate views are ordered


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  6. Tajmalzai A, Najah DM. Stercoral colitis due to massive fecal impaction: a case report and literature review. Radiol Case Rep. 2021;16(8):1946-1950. doi:10.1016/j.radcr.2021.04.067
  7. Weerakkody, Y.  Stercoral colitis.  1/22/22.