Studies have shown that 5-10% of all visits to the Emergency Department are for ‘abdominal pain’. This is not an easily algorithmable complaint, as the workup must be individualized based on history and physical examination. Even after a thorough workup and with a clear diagnosis, the disposition may not be so evident.
Let’s take colitis for instance:
‘Colitis’ refers to inflammation of the inner lining of the colon. It is one of the few conditions in which a fluoroquinolone (ciprofloxacin) is actually the first-line treatment [in combination with metronidazole].
Some patients can be discharged home with antibiotics:
Patients whose pain is controlled
Patients whose white blood cell count/lactic acid level are relatively close to normal
Patients whose symptoms (be they diarrhea, GI bleed, etc) are manageable on an outpatient basis
For the rest, consider starting IV antibiotics and admission to the hospital.
What if the radiologist interprets the CT scan as concern for ‘stercoral colitis‘: should this raise any special concerns?
Stercoral colitis develops when there is fecal impaction in the colon. This mass of dry, hard stool can lead to a focal pressure necrosis and subsequent colonic perforation. If the impaction is not removed, perforation and peritonitis may develop. Mortality rates once perforation has set in have been reported from 32% to 57%, with death often occurring in the first 24 hours.
Is manual disimpaction safe?
While impacted stool can cause perforation, disimpaction might produce a vagal reaction leading to arrhythmia, syncope, and other problems.
There is a case report of a patient who, while being disimpacted, suffered cardiac arrest secondary to vagal nerve stimulation and subsequent bradycardia. Granted, that patient was also hyponatremic, hyperkalemic, and on Lithium, but it led the authors to make the following recommendation: “Our recommendation would be to provide adequate analgesia and close patient monitoring of those patients undergoing this procedure who may require more than usual rectal manipulation due to significant stool burdens. Special consideration should also be applied to patients who are receiving increased rectal manipulation that have known electrolyte abnormalities and are on medications that may predispose them to fatal arrhythmias.”
Here’s what Tintinalli has to say on the subject: “Physician resistance to manual disimpaction does the patient a disservice, as enemas provide little or no relief…Manual disimpaction is a painful procedure for which patients may require sedation.”
Take-home message:
The next time you see ‘stercoral colitis’, don’t just discharge the patient home with antibiotics. Take a moment to reconsider and put on two sets of gloves.
