Fecaloma in Chronic Opioid-induced Constipation: A Fatal Case of Stercoral Colitis

Abstract

Stercoral colitis (SC) is a rare and potentially lethal condition characterized by severe colonic inflammation resulting from fecal impaction. This disorder is more prevalent among the elderly and vulnerable groups, especially those on chronic opioids. Our case study involves a 56-year-old male with a history of chronic opioid use who faced an acute colonic obstruction due to longstanding constipation. Despite receiving surgical treatment, the patient dies from ischemic bowel complications and multiorgan failure. The case accentuates the complexities of diagnosing and treating stercoral colitis, highlighting the critical need for early identification and proactive therapeutic intervention to prevent fatal outcomes.

1. Introduction

Stercoral colitis is an infrequent, yet severe gastrointestinal disorder marked by intense inflammation and ischemia of the colon due to fecal impaction.1 This condition typically escalates intraluminal pressure, leading to vascular compromise and potential ischemic necrosis of the colonic wall or perforation.2 While commonly observed in the elderly or debilitated individuals, younger patients with specific risk factors, such as opioid usage or prior substance use disorders, are also susceptible. Given that mortality rates in complex cases can exceed 60%, the clinical imperative for heightened vigilance and prompt treatment cannot be overstated. 3 This report delves into the rapid progression of stercoral colitis in a patient influenced by opioid-induced constipation, providing a detailed examination of the diagnostic, therapeutic, and clinical challenges encountered during management.4,5

2. Case presentation

A 56-year-old male with a notable history of heroin dependency, managed with methadone maintenance therapy, presented to the emergency department with acute abdominal pain. The pain was localized around the periumbilical area, described as colicky, with a severity of 7 out of 10 that increased in frequency and intensity over time. The abdominal pain was accompanied by recent changes in bowel habits, specifically looser stools, rather than chronic constipation, and the patient reported continued passage of flatus.

The patient’s medical history included chronic kidney disease stage 3a, hypertension, and asthma. His social history was significant for prolonged heroin use, which he had been managing through participation in a methadone program for over two years, with sporadic heroin use continuing along-side the treatment. No reported use of alcohol or tobacco.

Upon initial evaluation, the patient was hemodynamically stable, afebrile, and normotensive, with a normal heart rate. He appeared uncomfortable but was cooperative during the physical examination. Abdominal examination revealed localized tenderness in the right upper and lower quadrants without guarding or rebound tenderness. Bowel sounds were present. Initial laboratory tests, including Complete Blood Count and Comprehensive Metabolic Panel, were within normal limits. However, the patient’s abdominal pain continued to escalate. Electrocardiogram displayed sinus tachycardia with nonspecific T-wave changes. Computed Tomography scan of the abdomen and pelvis using both Intravenous and oral contrast, conducted 4 h post-admission, showed high-grade colonic obstruction with transition point in the mid to distal descending colon, emphasizing an oblong-shaped fecaloma measuring 11 cm in the cephalocaudal dimension and 4 cm in width x 4.5 cm anteroposterior, resembling a mass and initially mistaken for a foreign body due to its size and density (Fig. 1). To clarify the uncertain diagnosis of stercoral colitis, a small bowel series was performed, confirming a moderate extent of large bowel obstruction in the same location while ruling out the presence of a foreign body initially suspected in the CT scan. Surgical and gastroenterology teams were consulted (Fig. 2), who suggested conservative management.

Fig. 1.

CT abdomen and pelvis showing high-grade colonic obstruction with transition point in the mid to distal descending colon with an intraluminal indeterminant filling defect. Emphasizing fecalomainduced colonic obstruction in the descending colon.

Fig. 2.

Small bowel series show moderate obstruction in the mid to distal descending colon due to an 11.2 × 4.0 cm lamellated mass, likely an organized fecaloma.

Despite initial conservative management, including IV fluids, antibiotics, and bowel rest, the patient’s condition quickly deteriorated. His appearance started becoming more toxic; his heart rate escalated, and his blood pressure dropped from hypertensive levels to hypotension. Further investigations showed a marked elevation in serum lactic acid levels, rising from 11.0 mmol/L to 17 mmol/L over a few hours. The latest results showed an acute drop in hemoglobin, a leftward shift in white blood cell counts, a decline in platelets, and an increase in lactic acid levels (>20 mmol/L). The patient’s condition worsened leading to septic shock and multi-organ failure.

A decision was made to take the patient for an exploratory laparotomy, which revealed a frankly ischemic colon extending from the ileocecal to the descending colon with a movable mass in the descending colon, confirming the diagnosis of stercoral colitis. A subtotal colectomy was performed, leaving a discontinuity for a planned second-stage surgery. Postoperatively, the patient was managed in the intensive care unit for multiorgan failure. However, despite maximal efforts including mechanical ventilation and vasopressor support, the patient suffered multiple cardiac arrests and passed away.

3. Discussion

Stercoral colitis is a severe consequence of chronic constipation where impacted fecal matter causes sustained colonic pressure.1 The term “stercoral” is derived from the Latin word stercus, meaning feces. SC arises when hard, dry fecal matter accumulates and lodges in a hypomotile bowel segment. This dehydrated stool mass, referred to as fecaloma or stercoroma, exerts pressure on the colonic wall, leading to significant colonic distension and ischemia.6,2 The descending colon and rectosigmoid junction are especially vulnerable due to their anatomical location at Sudeck’s point, a watershed area with minimal collateral blood supply between the inferior mesenteric and superior rectal arteries.2,7 In our case, the patient’s chronic opioid use likely exacerbated colonic hypomotility, leading to chronic constipation, fecaloma formation, and subsequent ischemia.8

The classic clinical presentation of SC includes an elderly patient with a history of chronic constipation presenting with nonspecific abdominal pain, distension, nausea, and vomiting.3 Unlike other forms of colitis, diarrhea is notably absent in SC.9 However, more than half of patients present atypically, with presentations ranging from asymptomatic to an acute abdomen with peritoneal signs. This nonspecificity often mimics other abdominal pathologies, such as diverticulitis, appendicitis, or bowel obstruction, complicating diagnosis, especially in the context of overlapping comorbidities or neurologic/psychiatric disorders. Patients with complicated SC will additionally have signs of sepsis and peritonitis with impending perforation.4,5 Initially, our patient had nonspecific symptoms, indicating uncomplicated SC, but gradually progressed to complicated SC. Although plain radiographs can indicate SC, they are not specific or reliable. CT scans of the abdomen and pelvis with contrast are considered the gold standard, achieving a diagnostic accuracy of 82–90%.10 Typical findings include fecaloma, dilation of the colon, thickening of the bowel wall, and stranding of the pericolonic fat. In this case, the patient’s extensive opioid use history and the initial CT scan showing an obstruction caused by a fecaloma without clear perforation were the initial indicators of SC. Importantly, a longer segment of the affected colon (>40 cm) is linked to higher mortality rates.3

Management of SC involves relieving obstruction and addressing ischemic complications. Conservative measures, including bowel regimens and manual disimpaction, are preferred for uncomplicated cases.11 Endoscopic disimpaction as standard care, when done early, can prevent fecalith-induced bowel necrosis.12,13 Notably, opioids should be avoided for pain control as they exacerbate constipation, as seen in our patient.13 However, in complicated cases where perforation or ischemia is suspected, aggressive management with intravenous fluids, broadspectrum antibiotics (targeting gram-negative and anaerobic pathogens), and prompt surgical consultation is essential,13 as early intervention may decrease mortality. Prompt intervention is crucial to prevent the progression from uncomplicated to complicated stercoral colitis, as was the case in this patient. Given that CT abdomen and pelvis is the modality of choice for diagnosis, and when the CT findings are highly suspicious for colonic obstruction and fecaloma, obtaining further imaging modalities such as small bowel series could delay the treatment course. In such a critical case, early surgical intervention could have changed the outcome.

Ischemic bowel mandated surgical resection. The Hartmann procedure remains the standard for severe cases, as it minimizes septic complications and allows for eventual reanastomosis.5 Despite surgical intervention in our case, the patient’s advanced ischemia and systemic complications led to a fatal outcome, underscoring the importance of early detection and a multidisciplinary approach.

4. Conclusion

This case underscores the critical need for early recognition and intervention in stercoral colitis, especially in high-risk populations such as chronic opioid users. The patient’s rapid clinical deterioration highlights the life-threatening nature of fecaloma-induced colonic obstruction and stercoral colitis, and the importance of early endoscopic or surgical intervention which can theoretically improve the outcomes. Improved awareness and vigilance are essential for early diagnosis, reducing mortality, and achieving better outcomes in similar cases.