Pete Basford made the diagnosis!

This is the rectum in an elderly patient admitted following a stroke a weeks ago. A week after admission she started to complain of pain around the tailbone. A CT reported that the rectum was "non-specifically inflamed". This turned out to be an understatement (!) as the rectal mucosa is actually almost completely ulcerated from the anal verge up to the sigmoid junction! The sigmoid mucosa looked a little pale and oedematous but the patients albumin was only 22 g/L. There is no history of NSAID use. There is no known vascular disease and no past history of radiotherapy to the prostate. 
WHAT IS THE DIAGNOSIS? 

■ SOLITARY RECTAL ULCER SYNDROME

INCORRECT!

■ CROHN'S COLITIS

Nope!

■ ULCERATIVE COLITIS

Unfortunately not!

■ STERCORAL COLITIS

YES, you are right !

■ ISCHAEMIC COLITIS

No, the rectum has a HUGE blood supply!

explanation

I had just scoped this patient and knew that I was missing something important.  Why did his rectum look such a mess?!! 

Uploading the history and images onto FoE, I didn't wait for more than 20 minutes when Pete Basford (Consultant at Southlands Hospital) suggested a 'stercoral colitis'!   The Power of Friends of Endoscopy !!! The opinion of thousands of experienced doctors with a particular interest in Endoscopy available on your phone.  Awesome !  

Both CT and histology was of no use whatsoever just reporting 'severe rectal inflammation and ulceration'.  Nobody had 'joined the dots'!   Of course, the diagnosis is clinical, relying on recognising the pattern of a constipated, bedbound patient with severe rectal ulceration. Of course, when the patient turned up for a flexible sigmoidoscopy, the rectum was empty because of the enema!  An under recognised diagnosis! 

Impacted faeces lead to local pressure necrosis and the increased rectal pressure gives rise to mucosal ischaemia.  It's most common in the sigmoid and rectum because this is where the colonic pressure is the greatest.  Remember that the ulceration can be patchy. 

Of course it most commonly seen in elderly immobile patients with a history of chronic constipation, dementia, or inpatients immobilised after a stroke or who has been rendered bedbound for other reasons.   The feared complication is perforation which is usually fatal.