Stercoral Ulcer

A 73-year-old man with chronic constipation presented to the emergency department with hematochezia. Mild, colicky abdominal pain had begun 3 days earlier; obstipation had been present for 10 days.The patient’s history included a cerebrovascular accident 2 years earlier and Parkinson disease; he was taking anticholinergic drugs. Dr Virendra Parikh of Fort Wayne, Ind, noted mild tenderness in the lower abdomen and palpable hard stool in the rectum. The patient’s hemoglobin level was normal. A colonoscopy revealed an irregularly shaped, deep ulceration that occupied two thirds of the circumference of the rectum; the rest of the colon was normal. A stercoral ulcer of the rectum was diagnosed. The ulcer was friable; there was no active bleeding. Stercoral, or stercoraceous, ulcers result from pressure necrosis caused by hard and firm stools. They occur most frequently in the rectum and sigmoid colon and may present with sudden rectal bleeding. Endoscopic examination is essential to diagnose this condition. Endoscopic electrofulguration or epinephrine injection may be necessary to treat actively bleeding stercoral ulcers. These ulcerations often occur in constipated, bedridden patients. Perforation and peritonitis may be present in patients with long-standing ulcers. Nursing home residents and persons with multiple comorbid conditions who have ongoing constipation need appropriate and early therapy to avoid complications such as stercoral ulcers. This patient was given fiber therapy and stool softeners to normalize his bowel habits. The ulcer healed in 4 weeks. No evidence of recurrent bleeding has been detected.