Imaging Pearls ❯ Colon ❯ Stercoral Colitis
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- Stercoral colitis is an inflammatory reaction secondary to fecal impaction and almost always occurs in the setting of chronic constipation. Luminal distention caused by dense and dehydrated stool compresses the vascular supply of the distal colon, resulting in bowel ischemia and ulceration. Stercoral colitis primarily affects elderly patients, but it can be seen in any patient with decreased bowel motility, with risk factors including neurodegenerative disorders, chronic medical diseases, malignancy, immobility, and the use of narcotic or anticholinergic medications.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - The overlap of findings between stercoral colitis and other colonic diseases, particularly diverticulitis and malignancy, can sometimes make diagnosis challenging. Identification of fecal impaction and associated inflammatory changes helps in distinguishing stercoral colitis from other pathologic conditions. Prompt diagnosis of stercoral colitis and its complications allows appropriate management, which can range from preventive measures to emergent surgical treatment.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - Stercoral Colitis: Facts
The short segment of the colon between the branches of the inferior mesenteric and superior rectal arteries, known as the Sudeck point,marks the junction of the rectum and sigmoid colon. This region is a watershed territory with a relatively reduced blood supply and is susceptible to ischemia. - Stercoral Colitis: Facts
The pathophysiology of stercoral colitis is primarily driven by bowel-wall ischemia caused by luminal stool impaction. CT is the primary imaging modality to aid in diagnosing stercoral colitis and its potential complications. Identification of fecal impaction is essential for diagnosis. Inflammatory changes such as wall thickening and fat stranding typically are associated with the area affected by fecal impaction - The pathophysiology of stercoral colitis is primarily driven by bowel wall ischemia caused by luminal stool impaction. impacted fecal material in the colon causes compression of the colonic vasculature due to increased pressure on the wall. This results in ischemic injury and can lead to necrosis,ulceration, and colonic wall perforation in a stepwise fashion.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - On CT images, stool typically has a “soap bubble” appearance. In stercoral colitis, inspissated stool forms hard masses known as fecalomas. These fecalomas are more dense compared with normal stool and often contain calcifications or have a laminated appearance. The impacted stool collects in the affected colon and rectum, resulting in the characteristic fecal loading observed in stercoral colitis. Distention of the rectal diameter beyond 6–6.5 cm is generally considered abnormal, but this should be compared with that of the proximal portions of the colon.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - Extramural findings are associated with complications and are usually manifestations of ischemia leading to perforation. Stercoral perforation is associated with a mortality rate of 32%–59% due to extraluminal spillage of feces and the often rapid onset of feculent peritonitis . CT is particularly useful in the identification of direct sites of transmural injury or secondary signs of perforation, including mural discontinuity, extraluminal air, and perirectal fluid collection or abscess. . Extraluminal gas is easily identifiable on noncontrast CT images, but mural discontinuity may not be evident.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - Perirectal inflammatory changes favor stercoral colitis, as diverticula rarely form in the rectum. Perforated diverticulitis can resemble the extraluminal stool observed in perforated stercoral colitis, especially in cases in which a large diverticulum ruptures. However, the absence of colonic distention typically associated with fecal impaction favors diverticulitis as the likely underlying cause. Furthermore, stercoral ulcers and perforation sites commonly occur at multiple locations, in contrast to diverticulitis.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. - Stercoral colitis is essentially a form of ischemic colitis that is precipitated by chronic constipation. Although stercoral colitis is considered to be relatively rare in the literature, the authors believe this may be related to underdiagnosis due to nonspecific clinical presentations and overlap with other inflammatory bowel disorders. Stercoral colitis primarily affects the elderly, but the diagnosis should be considered in any patient with decreased bowel motility and appropriate imaging findings. CT is the standard modality for diagnosis, allowing accurate identification of characteristic findings as well as potential complications. Awareness of this condition and its findings allows appropriate management, ranging from supportive measures to surgical treatment.
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085. 
Stercoral Colitis: Review of Imaging Features and Complications.
Karkala N, Mathai B, Hines JJ Jr, Byun S, Katz DS.
Radiographics. 2025 Apr;45(4):e240085.
- “Stercoral colitis (also called stercoral proctitis if limited to the rectum) is an inflammatory condition of the bowel wall caused by fecal impaction. The resulting fecaloma leads to focal dilation of the bowel lumen and increased intraluminal pressure. When the pressure compromises vascular perfusion, this may lead to pressure-induced necrosis. The complications of this condition may range from subtle inflammatory findings to ulceration and, ultimately, even perforation.”
Stercoral colitis: CT imaging findings and clinical risk factors
Nicholas A. Zacharias · Meghan G. Lubner · Elizabeth S. Richards · Lu Mao · Perry J. Pickhardt
Abdominal Radiology (2023) 48:3050–3062 
Stercoral colitis: CT imaging findings and clinical risk factors
Nicholas A. Zacharias · Meghan G. Lubner · Elizabeth S. Richards · Lu Mao · Perry J. Pickhardt
Abdominal Radiology (2023) 48:3050–3062- “Beyond age, other reported risk factors for fecal impaction and stercoral colitis include neurocognitive conditions (e.g., dementia, cerebral palsy, spinal cord injury), disorders of the gastrointestinal tract (e.g., idiopathic constipation, colorectal cancer, inflammatory bowel disease), metabolic conditions and derangements (e.g., diabetes, uremia, hypothyroidism), and sites of anatomic narrowing. Medications such as opioids, anti-psychotics, anti-epileptics, and others that affect bowel motility may also play a role.”
Stercoral colitis: CT imaging findings and clinical risk factors
Nicholas A. Zacharias · Meghan G. Lubner · Elizabeth S. Richards · Lu Mao · Perry J. Pickhardt
Abdominal Radiology (2023) 48:3050–3062 - Colonic segment involvement of stercoral colitis and measurements are recorded in Table 2. The most common location of stercoral colitis involvement was the rectum (93.8%, n = 511, including 18 rectosigmoid cases). The rectum alone (proctitis) was implicated in 95.8% of mild cases (n = 433). Of the moderate-to-severe cases, the rectum alone was implicated in 81% (n = 59) of the cases without perforation compared with only 5% (n = 1) of those with perforation (p < 0.001). Sigmoid colonic involvement portended a more advanced presentation and was involved in 95% (n = 19) of perforated cases, including 13 cases without rectal involvement. In comparison, the sigmoid was involved in 16% (n = 12) and 2.4% (n = 11) of the moderate-to-severe cases without perforation and mild cases, respectively (p <0.001).
Stercoral colitis: CT imaging findings and clinical risk factors
Nicholas A. Zacharias · Meghan G. Lubner · Elizabeth S. Richards · Lu Mao · Perry J. Pickhardt
Abdominal Radiology (2023) 48:3050–3062 - “CT imaging features used to identify stercoral colitis in this study including luminal distention, colonic wall thickening, and surrounding inflammatory changes were similar to those reported in prior literature. The threshold of ≥ 3 mm to define wall thickening was typically utilized in prior studies, though Wu et al. reported cases without evidence of wall thickening (n = 10/23). Furthermore, we observed increasing thickness associated with increasing severity of the case. Though not required for diagnosis, other studies had reported unique features such as upstream colonic dilation, mucosal sloughing, and mesenteric hyperemia. Though the latter two features were not observed, upstream dilatory effect was observed in most cases, with 11% of the total cohort demonstrating findings of diffuse colonic distension with gas or fecal contents based on CT imaging reports. Prior studies also demonstrated similar imaging features associated with perforation, including pneumoperitoneum, developing abscess, free fluid, or extraluminal gas and stool.”
Stercoral colitis: CT imaging findings and clinical risk factors
Nicholas A. Zacharias · Meghan G. Lubner · Elizabeth S. Richards · Lu Mao · Perry J. Pickhardt
Abdominal Radiology (2023) 48:3050–3062
- “Stercoral colitis is an inflammatory colitis related to increased intraluminal pressure from impacted fecal material in the colon. This rare condition, first reported in 1894, has been described primarily in the surgical and gastrointestinal literature . As a result of the fecal impaction (a large mass of dry, hard stool that can develop because of chronic constipation), a focal pressure colitis may occur with ulceration resulting in colonic perforation. When stercoral colitis is associated with colonic perforation, a 35% mortality rate has been reported.”
Stercoral Colitis Leading to Fatal Peritonitis: CT Findings Heffernan C et al. AJR 2005;184:1189–1193 - “The sequence of events that can lead to fa-
tal colonic perforation is the development of fecal impaction, which causes increased intraluminal and colonic wall pressure. If left untreated, ischemic ulceration and perforation can ensue.”
Stercoral Colitis Leading to Fatal Peritonitis: CT Findings Heffernan C et al. AJR 2005;184:1189–1193 - “Fecal impaction leading to colonic obstruction is seen primarily in the elderly, often those who live in nursing homes or, less often, young pa- tients who are neurologically impaired. There is also an association with opiates, tricyclic antidepressants, and tranquilizers, most of which slow transit time through the bowel. Approximately 60% of patients who present with fecal impaction have a history of chronic constipation.” Stercoral Colitis Leading to Fatal Peritonitis: CT Findings Heffernan C et al. AJR 2005;184:1189–1193
- “The three most common locations for ster- coral ulceration are the anterior rectum just proximal to the peritoneal reflection, the anti- mesenteric border of the rectosigmoid junc- tion, and the apex of the sigmoid colon. Most cases are described as occurring on the antimesenteric side of the bowel wall. A pos- sible explanation is that the blood supply to the bowel enters on the mesenteric side and is relatively poor on the antimesenteric side, predisposing to ischemia.”
Stercoral Colitis Leading to Fatal Peritonitis: CT Findings Heffernan C et al. AJR 2005;184:1189–1193 - “Because most cases of uncomplicated stercoral colitis are successfully treated with disimpaction, a histologic diagnosis is not often obtained. In most cases of uncomplicated fecal impaction, the colon
wall should be thin without adjacent fat stranding. The imaging findings of colonic wall thickening and pericolonic fat stranding suggest colitis. When associated with fecal impaction and in the right clinical setting, these findings should suggest stercoral colitis.”
Stercoral Colitis Leading to Fatal Peritonitis: CT Findings Heffernan C et al. AJR 2005;184:1189–1193 - “Necrotic stercoral colitis is a necrotic process that occurs in stercoral colitis (SC), caused by fecal impaction that results in pressure ulceration and regional necrosis. Perforation is rare, but has a mortality rate of 32%-57%. Early diagnosis with aggressive bowel cleansing and disimpaction may decrease the pressure and lessen the likelihood of ulceration of the colon. Fecal impaction frequently occurs in elderly patients, and those who are bed-ridden for a prolonged period of time.”
Necrotic stercoral colitis: Importance of computed tomography findings Cheng-Hsien Wu et al. World J Gastroenterol. 2011 Jan 21; 17(3): 379–384. - “Fecal impaction and perforation occur most often in the sigmoid colon. The sigmoid colon is the narrowest region of the entire colon, and passage of stools with a more solid consistency can be difficult. In such cases, fecaloma exerts localized pressure on the walls of the sigmoid colon, the area with the most precarious vascular supply, especially the vascular region known as Sudeck’s point. Prolonged localized pressure and ischemia can give rise to pressure ulceration.”
Necrotic stercoral colitis: Importance of computed tomography findings Cheng-Hsien Wu et al. World J Gastroenterol. 2011 Jan 21; 17(3): 379–384. - “NSC differs from other colitis by absence of diarrhea clinically. It can be confirmed by intraoperative and histological findings. At surgery, stercoral ulcers and perforations are usually found on the anti-mesenteric side; ulcerations usually have sharp margins and measure 1-10 cm, and are occasionally multiple. Histological findings include sharp demarcation without undermining at ulcer margins, and transmural necrosis at the perforated site. Treatment is usually resection of the affected bowel, colostomy, and Hartmann’s procedure.”
Necrotic stercoral colitis: Importance of computed tomography findings Cheng-Hsien Wu et al. World J Gastroenterol. 2011 Jan 21; 17(3): 379–384.