The "Fecal" breath: a case report of acute hypoxic respiratory failure from fecal aspiration with stercoral colitis in chronic constipation.

Introduction: Stercoral colitis (SC) is a rare but life-threatening inflammatory condition resulting from fecal impaction. Although typically presenting with abdominal complaints, atypical extra-abdominal manifestations may occur. This case report describes an unusual presentation of SC complicated by acute hypoxic respiratory failure due to fecal aspiration, underscoring the diagnostic challenges and importance of early recognition. Case Presentation: A 66-year-old man with a history of chronic opioid use and longstanding constipation presented with generalized weakness, lethargy, and respiratory distress. On arrival, he was hypotensive, hypoxic, and noted to have a fecal odor to his breath. Laboratory evaluation revealed lactic acidosis, acute kidney injury, and leukopenia. Imaging demonstrated severe fecal impaction with SC and right lower lobe pneumonia. Bronchoscopy confirmed fecal material within the airway. He required mechanical ventilation, vasopressors, broad-spectrum antibiotics, antifungal therapy, and aggressive bowel disimpaction, including laxatives, enemas, and manual evacuation. With multidisciplinary management, he recovered and was discharged after 8 days, returning to baseline bowel function. Discussion: This case highlights an exceptionally rare complication of SC - fecal aspiration leading to acute respiratory failure and sepsis. The pathophysiology likely involves opioid-induced hypomotility and fecal impaction with regurgitation of fecal material into the airway. Treatment requires not only bowel decompression and antimicrobial therapy but also airway protection and bronchoscopy in cases of aspiration. Prognosis depends on timely recognition, as delayed diagnosis is associated with high morbidity and mortality. Conclusion: SC should be considered in at-risk patients with chronic constipation and opioid use, even when presenting with respiratory complaints. Awareness of its atypical manifestations, including aspiration pneumonia, is crucial for prompt intervention and improved outcomes.