A giant fecaloma causing stercoral colitis secondary to aripiprazole and benztropine: A case report

Abstract

Background: Fecaloma is a mass of hardened feces impacted in the rectum and sigmoid. When the colonic mucosal wall and vasculature are compressed, stercoral colitis, a rare type of inflammatory colitis, may occur. Despite being connected to psychiatric patients and antipsychotic medications in the literature, fecaloma remains a significant, yet often overlooked, cause of morbidity and mortality in this population.

Case presentation: A 43-year-old patient with schizophrenia being treated with aripiprazole and benztropine lost follow-up and eventually presented to the emergency department with a giant fecaloma and associated stercoral colitis. She was managed with oral and rectal laxatives and supportive therapy. Additionally, aripiprazole was discontinued.

Discussion: Antipsychotics have been associated with constipation, fecaloma, and stercoral colitis due to their anticholinergic properties. Benztropine, an antimuscarinic drug commonly used in psychiatric patients to alleviate extrapyramidal symptoms, may further decrease gastrointestinal mobility. Fecaloma and associated stercoral colitis are often diagnosed via imaging, typically a computed tomography scan of the abdomen. Management depends on the severity and generally ranges from conservative treatment to surgical options.

Conclusion: This case describes a schizophrenic patient undergoing treatment with aripiprazole and benztropine who presented with constipation and was diagnosed with a giant fecaloma complicated by stercoral colitis. The patient was managed successfully with aggressive laxatives and discontinuation of aripiprazole. Early recognition and prompt management of fecaloma are essential to mitigate associated complications. In addition, it is important to recognize risk factors for constipation and regularly review home medications, such as antipsychotics, that may cause constipation as a side effect.

Keywords: Antipsychotics; aripiprazole; benztropine; constipation; fecaloma; stercoral colitis.

Figure 1

A CT scan of the abdomen and pelvis with IV contrast shown in axial (A) and coronary views (B). Images demonstrating massively dilated large bowel loops due to severe fecal loading occupying the entire abdomen and compressing other abdominal structures. Wall thickening and peri-colonic soft tissue stranding noticed, consistent with stercoral colitis.

Figure 2

Abdominal XR while standing showing dilated bowel loops filled with fecal material pushing the small bowels and the stomach upwards with air-fluid level (A). After treatment with laxatives, significant improvement of fecal loading and resolution of mass effect on small bowels and stomach noted (B).