**Background:** Stercoral colitis is a rare inflammatory colitis caused by fecaloma impaction leading to pressure necrosis, increased intraluminal pressure, and risk of ischemia, ulceration, and perforation. It carries high morbidity and mortality, often due to delayed diagnosis. While predominantly reported in the elderly, chronic constipation is common across pediatric developmental stages and in subgroups with congenital anorectal malformations, autism spectrum disorder, and mental health disorders. Pediatric cases remain extremely limited, with total reported cases in the single digits.
**Methods:** This is a single case report of an 18-year-old female with a complex medical history including anorectal malformation, prior colostomy with reversal, Malone antegrade colonic enema (MACE) placement for chronic constipation, neurogenic bladder, and anxiety and depression. She presented with worsening abdominal pain for 3 days, intractable vomiting, and absent bowel movements for 2 weeks despite numerous MACE and rectal enemas. Physical exam revealed abdominal guarding without peritoneal signs. Initial labs showed leukocytosis (WBC 14.36 k/mm³), elevated CRP (14.0 mg/dL), and elevated lactate (3.0 mmol/L). Abdominal radiograph showed transverse colon dilatation, and CT with intravenous contrast revealed a large rectal stool burden with marked rectal wall thickening and submucosal enhancement, diagnostic for stercoral colitis. Blood cultures were obtained and broad-spectrum antibiotics initiated. After failed conservative disimpaction (rectal castile soap enemas, MACE osmotic laxatives, digital rectal manipulation), endoscopic disimpaction was performed.
**Key Results:** Endoscopic visualization revealed a large fecaloma in the proximal rectosigmoid with stool burden extending to the hepatic flexure. Repetitive irrigation was required to break down stool debris. Post-disimpaction, mucosal findings included erythema and closely clustered superficial ulcerative lesions lining the rectosigmoid area where the fecaloma had resided. The patient was discharged the following day with complete resolution of symptoms. Laboratory markers normalized: WBC 5.86 k/mm³, CRP 2.8 mg/dL, lactate 1.0 mmol/L. Blood cultures showed negative growth.
**Clinical Implications:** This case demonstrates that stercoral colitis can occur in adolescents, particularly those with risk factors for chronic constipation including congenital anorectal malformations. CT with intravenous contrast remains the diagnostic gold standard, with features including colonic distension, focal wall thickening (commonly rectosigmoid), and pericolonic fat stranding indicating edema or ischemia. Endoscopic disimpaction is the standard of care for nonoperative management, offering direct visualization, severity assessment, and expedited fecalith removal. Early recognition and aggressive management are critical to prevent progression to ischemic colitis, sepsis, and perforation. Clinicians should maintain suspicion for stercoral colitis across all age groups, especially in patients with chronic constipation risk factors, as delayed diagnosis contributes significantly to morbidity and mortality.