A pediatrician was reviewing some radiographs and overheard the radiology fellow talking with some learners about a patient with stercoral colitis. “This patient doesn’t have it, but see how there is bowel inflammation here? So that should be on your general differential diagnosis of bowel inflammation. We don’t see it much in kids but it has a high morbidity and mortality in adults. All you budding internists, emergency room docs and surgeons need to know about stercoral colitis,” he remarked.
Figure 148. Axial CT with contrast of the abdomen (above) shows marked diffuse wall thickening and mucosal enhancement of the transverse colon. Wall thickening and mucosal enhancement is also present but less pronounced in the descending colon on the coronal CT (below left) and rectum (below right). The colon is filled with a marked amount of stool from the cecum to the rectum.
Discussion
The gastrointestinal system provides lots of feedback to the brain that is usually unconsciously occurring as it breaks down food, absorbs the nutrients and eliminates waste. Sensations from the GI tract do come to our awareness though at important times. The sensation of stomach fullness causes us to stop eating and drinking. The sensation of rectal fullness causes us to toilet. Nausea occurs when something is causing irritation (e.g. food poisoning) and the body may induce emesis to try to remove the irritation. Similarly increased peristalsis may hasten the transit of the irritation (e.g. infectious diarrhea) though the body and evacuate it. Emesis causes a variety of unpleasant sensations, and increased peristalsis is often perceived as abdominal pain. Stretching of the bowel does cause abdominal pain and is commonly seen in constipation and encopresis. The pain/unpleasant sensation is trying to signal that the bowel needs evacuation, but for many reasons (e.g. stubborn toddler), this is being overridden by the brain and not occurring. This causes more stool to build up and therefore more stretching, peristalsis and potential for the perception of pain that happens with impaction. If this occurs long enough, the body may not appear to pay attention to those signals and the peristalsis/evacuation may not occur in normal ways. This causes constipation/encopresis and all of their potential problems.
Older school age and junior high aged patients often become more aware of normal body sensations, especially around the time of puberty, and normal body, especially GI sensations may be perceived by some as abnormal. Most parents will monitor the child and point out the normality of what is occurring, but some patients may end up in the office seeking help for “abdominal pain”.
A review of constipation causes can be found here.
Learning Point
Stercoral colitis is “…caused by increased intraluminal and colonic wall pressure from a fecaloma (a large mass of dry, hard stool).” It is thought that the increased pressure causes bowel ischemia which can cause ulceration and/or perforation. It is more common in the sigmoid colon as “…it is the narrowest portion of the colon, has the lowest blood supply, and is the area of maximal dehydration of feces.” It is estimated that up to 3.2% of colonic perforations are due to stercoral colitis. It is most common in the geriatric population and has a mortality rate of 35-60%%. Risk factors include geriatric age group, sedentary life-style including problems that increase it such as cerebral palsy or paresis, mental health issues around toileting, opiate use, diabetic enteropathy, and hypothyroidism.
Stercoral colitis with or without perforation is uncommon in pediatrics. Presentation due to perforation in all age groups is more common probably as it presents with peritoneal signs. Patients are treated with bowel decompression if not perforated, and need surgical treatment if perforated and antibiotics for peritonitis.
Patients overall but those without perforation potentially may be underdiagnosed. “Stercoral colitis is an uncommon pediatric disease and one that may be unknown among physicians who have not also had an adult practice.” It should be considered in the differential diagnosis of patients with a history of constipation and persistent abdominal pain.
Questions for Further Discussion
1. What causes recurrent abdominal pain? A review can be found here
2. What causes acute abdominal pain? A review can be found here
3. What causes abdominal distension? A review can be found here
4. What causes rectal prolapse? A review can be found here
Related Cases
- Disease: Stercoral Colitis | Constipation
- Symptom/Presentation: Abdominal Pain | Constipation and Encopresis
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Abdominal Pain and Constipation.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Canders CP, Shing R, Rouhani A. Stercoral Colitis in Two Young Psychiatric Patients Presenting with Abdominal Pain. The Journal of Emergency Medicine. 2015;49(4):e99-e103. doi:10.1016/j.jemermed.2015.04.026
Caillet A, Steiner M, Sawaya D, Nowicki M. Stercoral Colitis With Silent Perforation in a Child. J Clin Gastroenterol. 2016;50(9):799-800. doi:10.1097/MCG.0000000000000610
Unal E, Onur MR, Balci S, Gormez A, Akpinar E, Boge M. Stercoral colitis: diagnostic value of CT findings. Diagn Interv Radiol. 2017;23(1):5-9. doi:10.5152/dir.2016.16002
Proulx E, Glass C. Constipation-Associated Stercoral Colitis. Pediatr Emerg Care. 2018;34(9):e159-e160. doi:10.1097/PEC.0000000000001600
Derrick DK, Azeez L, Barragan M. Pediatric Stercoral Colitis and Acute Kidney Injury From Chronic Constipation. Clin Pediatr (Phila). 2024;63(11):1592-1596. doi:10.1177/00099228241226501
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa