Stercoral colitis is a form of colitis caused by fecal impaction distending the colon and causing fecaloma formation. Fecalomas lead to pressure necrosis of the colon and eventual perforation. The increased intraluminal pressure from the distention of the colon causes vascular compromise and ischemia. The most common locations of necrosis are in the sigmoid colon and rectum . When progressed to perforation, the mortality rate is as high as 60%. The most common cases of stercoral colitis occur in nursing home patients, mentally impaired patients, or those with chronic constipation. Here we describe an unusual case of stercoral colitis causing septic shock, provoked by opioids

Delancy, Anna

Espinosa, James

Lucerna, Alan

Tomasello, Nicholas

Wiley, Joan

English

Rowan University

Rowan University Rowan Digital Works Stratford Campus Research Day 27th Annual Research Day May 4th, 12:00 AM When Constipation Becomes Lethal: Septic Shock Induced by Stercoral Colitis In A 77-Year-Old Female Anna Delancy Jefferson Health Nicholas Tomasello Jefferson Health Joan Wiley Rowan University James Espinosa Rowan University Alan Lucerna Rowan University Follow this and additional works at: https://rdw.rowan.edu/stratford_research_day  Part of the Bacterial Infections and Mycoses Commons, Digestive System Diseases Commons, Emergency Medicine Commons, Gastroenterology Commons, and the Pathological Conditions, Signs and Symptoms Commons Let us know how access to this document benefits you - share your thoughts on our feedback form. Delancy, Anna; Tomasello, Nicholas; Wiley, Joan; Espinosa, James; and Lucerna, Alan, "When Constipation Becomes Lethal: Septic Shock Induced by Stercoral Colitis In A 77-Year-Old Female" (2023). Stratford Campus Research Day. 89. https://rdw.rowan.edu/stratford_research_day/2023/may4/89 This Poster is brought to you for free and open access by the Conferences, Events, and Symposia at Rowan Digital Works. It has been accepted for inclusion in Stratford Campus Research Day by an authorized administrator of Rowan Digital Works. When Constipation Becomes Lethal: Septic Shock Induced by Stercoral Colitis In A 77-Year-Old FemaleAnna Delancy DO1, Nicholas Tomasello DO1, Joan Wiley DO2, James Espinosa MD1, Alan Lucerna DO11Department of Emergency Medicine, Jefferson Health New Jersey2Department of Critical Care, Jefferson Health New Jersey Conclusions:Stercoral colitis can be a fatal disease and should be suspected in elderly and chronically constipated patients presenting with abdominal pain. CT imaging is the most important diagnostic imaging tool for diagnosing stercoral colitis. Complications of stercoral colitis such as bowel perforation or those seen in this case of a 77-year-old female such as septic shock secondary to bacterial translocation of fecaloma can be disastrous and must be diagnosed and managed promptly in this potentially lethal condition to avoid further complications. Abstract:Stercoral colitis is a form of colitis caused by fecal impaction distending the colon and causing fecaloma formation. Fecalomas lead to pressure necrosis of the colon and eventual perforation. The increased intraluminal pressure from the distention of the colon causes vascular compromise and ischemia. The most common locations of necrosis are in the sigmoid colon and rectum [1]. When progressed to perforation, the mortality rate is as high as 60%. The most common cases of stercoral colitis occur in nursing home patients, mentally impaired patients, or those with chronic constipation. Here we describe an unusual case of stercoral colitis causing septic shock, provoked by opioids.Case Presentation: A 77-year-old female with past medical history of advanced Alzheimer's dementia, hypertension, chronic constipation presented to the ED by EMS from a memory care facility with chief complaint of hypotension. Further history and review of symptoms were unable to be obtained due to patient’s cognitive status. From facility paperwork it was noted that patient sustained a recent fall resulting in a left elbow fracture and left patellar fracture which were status post surgical repair 8 days prior to her presentation to the ER.  The patient had been started on oxycodone after the initial fall and was taking it daily for analgesia.On presentation, her vital signs were blood pressure of 78/56 mmHg, heart rate of 91 beats per minute, respiratory rate of 16 breaths per minute, temperature 98.1 degrees Fahrenheit orally, and a pulse oximetry of 96% on room air. Her Body Mass Index was 28.6 kg/M2.Physical examination revealed an ill-appearing elderly female who was pleasantly confused. The private nurse who accompanied the patient to the hospital reported that the patient appeared more fatigued than her baseline. There was a hard cast present on the left forearm and long knee immobilizer present on the left knee. There was generalized abdominal tenderness to palpation in all four quadrants with voluntary guarding. Her capillary refill was noted to be delayed between 2-3 seconds. The remainder of the physical exam was unremarkable. An X-ray of the left knee, X-ray of the left forearm, X-ray of the left elbow, CT of the head were obtained which showed no acute abnormalities. An X-ray of the chest was performed which showed no acute process however noted a moderate hiatal hernia. A CT of the abdomen and pelvis without contrast was performed which showed large amount of retained stool, a distended rectum, cholelithiasis without cholecystitis, and wall thickening with stranding of the descending colon, sigmoid, and rectum due to stercoral colitis. An electrocardiogram showed sinus rhythm with premature supraventricular complexes without acute ST segment or T wave changes. Labwork was completed revealing a high sensitivity troponin of 26, creatinine kinase of 363, lactate of 1.6. A complete blood count revealed a white blood cell count of 37.5 with a bandemia of 13 and a normal hemoglobin of 12.8. A basic metabolic panel revealed a creatinine of 5.17. Urinalysis was unremarkable. Patient was given 1 liter of intravenous normal saline however her hypotension persisted. Given these laboratory findings in conjunction with the vital signs and CT imaging results, the patient was deemed to have severe sepsis with septic shock secondary to stercoral colitis, requiring peripheral vasopressors. Her septic shock was due to presumed bacterial translocation of fecal impaction secondary to her immobility and opiate induced worsening of chronic constipation. She was started on broad spectrum IV antibiotics (vancomycin and piperacillin-tazobactam) and admitted to the intensive care unit. Gastroenterology, Nephrology, and Infectious Disease were consulted. She successfully underwent manual disimpaction by GI the following day and completed a 7-day course of piperacillin-tazobactam. Her acute kidney injury, which was secondary to decreased intravascular volume in the setting of hypotension, resolved, and she did not require any hemodialysis. After 9 days in the hospital, the patient was deemed medically stable for discharge to a subacute rehabilitation center.Discussion:It is paramount that emergency physicians and general surgeons have a high index of suspicion for this condition. Not only does stercoral colitis present a diagnostic challenge due to patient population affected, but also carries a high mortality risk as it mimics other common abdominal pathologies which can further delay diagnosis.The pathophysiology derives from the number one risk factor which was identified in 100% of patients presenting with stercoral colitis: chronic constipation [2]. In conjunction of other risk factors such as bed bound status, chronic opioid use, or an elderly patient with cognitive decline - fecal matter continues to stagnate. This results in the continued increase in volume of stool burden leading to worsening impaction and the formation of a fecalith, or a hardened stool ball. These fecalomas are found in the sigmoid colon or the rectum 77% of the time due to these areas being the narrowest part of the colon with the least water content [1]. These fecaliths cause compression of the colonic wall vascular supply, causing decreased blood flow, and eventual ulceration or pressure necrosis of the bowel ensues. Another sequelae of this is ischemic colitis, which is brought upon by fecalomas causing bowel dilatation. Once a fecaloma is large enough, the vasculature of an entire segment of affected bowel can become compressed causing ischemic colitis. If not treated urgently, the ulceration can result in bowel perforation which is arguably one of the endpoints along with bowel involvement of more than 40 cm that predict the highest risk of mortality in this disease, as it leads to peritonitis and a rapid bacteremia [3].Computed topography of the abdomen and pelvis without contrast remains the imaging modality of choice [4]. Presence of a large fecaloma with distention of the affected colon and wall thickening and pericolonic fat stranding should alert radiologists and surgeons to this potentially fatal condition.Patients who do not show signs of peritonitis can be managed non-operatively with bedside manual disimpaction via the rectum or with endoscopically guided disimpaction, a bowel regimen, and admission for close monitoring [5]. Laxatives are not recommended due to risk of perforation until the fecaloma is removed. Given length of the ischemic segment of colon involved early surgical evaluation is recommended. Primary operative management of stercoral colitis is reserved for patients with perforation, patients who have large segments of ischemic bowel involvement, or if conservative management fails. Treatment for these patients involves resection of the affected bowel, colostomy, and a Hartmann pouch [6]. Opioids should be avoided for analgesia due to further decrease in colonic motility. Patients with signs of sepsis or septic shock should be resuscitated as needed with IV fluids and broad-spectrum IV antibiotics that cover for gram-negative and anaerobic organisms [7].References:  1. Morano C, Sharman T. Stercoral Colitis. 2023 Jan;. PubMed PMID: 32809443.2. Saksonov M, Bachar GN, Morgenstern S, Zeina AR, Vasserman M, Protnoy O, Benjaminov O. Stercoral colitis: a lethal disease-computed tomographic findings and clinical characteristic. J Comput Assist Tomogr. 2014 Sep-Oct;38(5):721-6. doi: 10.1097/RCT.0000000000000117. PubMed PMID: 24887575.3. Celayir MF, Köksal HM, Uludag M. Stercoral perforation of the rectosigmoid colon due to chronic constipation: A case report. Int J Surg Case Rep. 2017;40:39-42. doi: 10.1016/j.ijscr.2017.09.002. Epub 2017 Sep 14. PubMed PMID: 28934715; PubMed Central PMCID: PMC5607122.4. Tajmalzai A, Najah DM. Stercoral colitis due to massive fecal impaction: a case report and literature review. Radiol Case Rep. 2021 Aug;16(8):1946-1950. doi: 10.1016/j.radcr.2021.04.067. eCollection 2021 Aug. PubMed PMID: 34149980; PubMed Central PMCID: PMC8193071.5. Okullo A, Alsnih G, Kwok T. An Unusual Case of Stercoral Perforation in a Patient with 86 cm of Small Bowel. Case Rep Surg. 2013;2013:317250. doi: 10.1155/2013/317250. Epub 2013 Sep 9. PubMed PMID: 24106633; PubMed Central PMCID: PMC3782821.6. Chopra A, Rothstein A, Mohamed Ahmed A, Pannell S. Small Bowel Evisceration Through a Perforated Stercoral Ulcer. Am Surg. 2022 Feb 5;:31348221075733. doi: 10.1177/00031348221075733. [Epub ahead of print] PubMed PMID: 35128955.7. Reategui C, Grubbs D. Non-perforated Stercoral Colitis patients with septic shock have a higher mortality than their perforated counterparts. A case report and review of literature. Int J Surg Case Rep. 2022 Sep;98:107528. doi: 10.1016/j.ijscr.2022.107528. Epub 2022 Aug 17. PubMed PMID: 36030766; PubMed Central PMCID: PMC9428845.Figure 1 and Figure 2: Coronal views of computed tomography imaging of the abdomen and pelvis showing rectum distended to 9 cm, wall thickening and adjacent stranding of the descending colon, sigmoid and rectum consistent with stercoral colitisFigure 1                                                                                              Figure 2

When Constipation Becomes Lethal: Septic Shock Induced by Stercoral Colitis In A 77-Year-Old Female

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When Constipation Becomes Lethal: Septic Shock Induced by Stercoral Colitis In A 77-Year-Old Female

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