Stercoral Colitis in an Elderly Patient With Bipolar Disorder: A Diagnostic Challenge

ABSTRACT

Stercoral colitis can develop rapidly and present atypically in elderly patients, particularly those with cognitive impairment and psychiatric illness, where nonspecific symptoms may delay diagnosis. Clinicians should maintain a high index of suspicion, especially in socially vulnerable individuals where elder neglect, malnutrition, and poor functional status may further obscure the clinical picture.

Summary.

• Stercoral colitis is an uncommon, life‐threatening condition that can present with nonspecific symptoms in elderly patients.

• CT imaging is essential for rapid diagnosis.

• Multidisciplinary care (geriatrics, psychiatry) is crucial for optimal management.

• Social factors like elder neglect and malnutrition complicate diagnosis and treatment.

1. Introduction

Stercoral colitis (SC) is an uncommon, life‐threatening condition characterized by colonic inflammation and pressure necrosis resulting from fecal impaction. The buildup of impacted stool can compromise vascular supply, leading to ischemic injury, full‐thickness necrosis, or even perforation [1]. Recent large‐scale retrospective data from U.S. hospitals found SC noted in only 0.008% of abdominal and pelvic CT scan impressions among patients aged 65 or older, and 0.003% among all ages. Importantly, mortality rates are substantial, ranging from 32% to 60% in cases complicated by perforation [2].

Diagnostic challenges are amplified in patients with psychiatric comorbidities such as bipolar disorder and cognitive impairment, which may mask typical physical symptoms and delay recognition of life‐threatening pathology [3]. Additionally, concerns regarding elder neglect, as suggested by marked and unexplained weight loss, further complicate both diagnosis and management. We report a case of rapidly progressive SC in a geriatric patient with bipolar disorder, cognitive impairment, and malnutrition, emphasizing the multifactorial nature and diagnostic complexity of this condition.

2. Case History/Examination

A 63‐year‐old woman with a medical history of bipolar disorder, cognitive impairment, diverticulosis, and chronic back pain presented to the adult medicine clinic on May 27, 2024, with complaints of poor oral intake, significant weight loss, and abdominal pain. Her family reported a 6 kg weight loss over the previous 2 months and 18 kg over the past year, raising concerns about elder neglect. Due to ongoing abdominal pain, she was then referred to the emergency department for further evaluation.

The patient had been hospitalized 2 months prior (March 26, 2024) at another institution for similar complaints. A CT scan performed at that time showed no evidence of SC or diverticulitis, suggesting a structurally intact colon.

On presentation to our facility, she was found to be malnourished, with moderate protein‐calorie malnutrition, adult failure to thrive, and acute hypokalemia. A repeat CT abdomen/pelvis with IV contrast on May 27, 2024, revealed distention of the rectal vault with fecal material and mural thickening, findings concerning for SC (Figure 1). Of note, the radiology report initially misstated diverticulitis; however, the patient has a history of diverticulosis, not active diverticulitis.

FIGURE 1.

| Axial CT image of the pelvis showing marked distention of the rectal vault (center) with dense fecal material and associated mural thickening (arrow), consistent with stercoral colitis.

3. Differential Diagnosis, Investigations, and Treatment

Her hemoglobin levels trended downward during admission (from 11.1 to 8.8 g/dL), suspected to be dilutional anemia due to fluid resuscitation. GI evaluation, including an EGD performed on May 28, showed no acute mucosal abnormalities. Ferritin, folate, and B12 levels were within acceptable ranges (Ferritin: 200, Folate: 11, B12: 412).

The patient was evaluated by geriatrics and psychiatry services. Mirtazapine was initiated to improve appetite. She remained hemodynamically stable throughout hospitalization and responded to bowel regimens including lactulose, polyethylene glycol, and senna. The patient remained hemodynamically stable throughout the hospitalization and showed significant improvement in her abdominal pain and overall condition.

4. Conclusion and Results (Outcome and Follow‐Up)

The patient responded well to the bowel regimen, and her pain gradually resolved. She was discharged in an improved condition on May 31, 2024. Follow‐up was scheduled with her primary care physician, and recommendations for continued management of SC, including dietary modifications and regular monitoring, were provided.

5. Discussion

The term stercoral derives from the Latin word stercus, meaning feces. In SC, hard, dry fecal matter accumulates in a hypomotile bowel, forming a fecaloma that exerts pressure on the colonic wall. This results in vascular compression, impaired perfusion, and localized inflammation. As intraluminal pressure exceeds capillary perfusion, ischemic damage may occur, progressing to ulceration, necrosis, or even perforation. If perforation ensues, fecal contamination of the peritoneum can lead to sepsis and high mortality [4].

SC predominantly affects elderly individuals with chronic constipation, particularly those who are bedbound, cognitively impaired, or living in long‐term care facilities. Although typically seen in patients over 60, it may also develop in younger individuals with psychiatric illness, opioid use, or chronic conditions contributing to bowel hypomotility [4, 5, 6]. Our patient, a 63‐year‐old woman with bipolar disorder, cognitive decline, and functional deterioration, represents a high‐risk demographic.

Clinical presentation is often nonspecific. While patients may report abdominal pain and distension, SC is typically not associated with diarrhea—unlike other forms of colitis—and lacks standardized diagnostic criteria [4, 7]. In this case, subtle signs such as poor oral intake, weight loss, and abdominal discomfort raised concern. However, cognitive and psychiatric comorbidities can mask typical symptoms, delaying diagnosis.

CT imaging with IV contrast remains the gold standard for diagnosis, offering an estimated 82%–90% accuracy in detecting stercoral complications such as perforation [4, 8]. In this case, CT findings of rectal vault distension with fecal loading and mural thickening confirmed the diagnosis. Notably, a prior CT 2 months earlier had been normal, underscoring the potential for rapid disease progression.

Initial radiology misinterpretation as diverticulitis further complicated the case, especially given her known history of diverticulosis but no active diverticulitis. Such diagnostic ambiguity emphasizes the importance of clinical correlation and awareness of SC in high‐risk patients.

There are no formal management guidelines for SC. In the absence of perforation, conservative treatment—such as bowel regimens, enemas, and manual or endoscopic disimpaction—is appropriate [4]. Our patient improved with oral agents including lactulose, polyethylene glycol, and senna. Opioids were avoided to prevent worsening constipation. Mirtazapine was introduced to stimulate appetite and support nutritional recovery.

Multidisciplinary collaboration, including input from geriatrics, psychiatry, and gastroenterology, played a key role in management. Early surgical consultation is recommended in cases with signs of perforation or clinical deterioration [4].

In conclusion, SC can develop rapidly in geriatric patients with functional and cognitive decline. Early recognition, repeat imaging when clinical status changes, and comprehensive care addressing both medical and social needs are essential. This case also highlights the value of interdisciplinary collaboration and the need for vigilance in potentially neglected elderly individuals.

Author Contributions

Nischal Shrestha: conceptualization, data curation, investigation, methodology, project administration, resources, software, writing – original draft, writing – review and editing. Radhika Vij: supervision, writing – review and editing. Ritesh Luitel: writing – review and editing.

Ethics Statement

The authors have nothing to report.

Consent

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

Conflicts of Interest

The authors declare no conflicts of interest.

Shrestha N., Vij R., and Luitel R., “Stercoral Colitis in an Elderly Patient With Bipolar Disorder: A Diagnostic Challenge,” Clinical Case Reports 13, no. 11 (2025): e71466, 10.1002/ccr3.71466.

Data Availability Statement

The authors have nothing to report.