Atypical Stercoral Colitis in Chronic Opioid Use With Concurrent Hepatic and Pulmonary Lesions.

Stercoral colitis (SC) is a life-threatening inflammatory condition caused by fecal impaction and chronic opioid-induced dysmotility. While classically presenting with abdominal pain, atypical presentation can lead to diagnostic delays and increased morbidity. A 72-year-old woman with chronic intranasal fentanyl use presented with localized rectal pain and overflow diarrhea. Initial imaging revealed SC but also identified cavitary pulmonary lesions and a hepatic mass. This constellation of findings initially raised high suspicion for disseminated malignancy. However, biopsy demonstrated inflammatory infiltrates consistent with hepatic abscess formation, raising concern for possible bacterial translocation from compromised colonic mucosa, although a definitive causal relationship could not be established. The patient was successfully managed with aggressive manual disimpaction and broad-spectrum antibiotics. This case illustrates the diagnostic complexity of SC, where concurrent systemic inflammatory findings may mimic metastatic disease and broaden the differential diagnosis considerably. It underscores the importance of considering possible gastrointestinal sources of systemic inflammation or infection in patients with severe SC and multiorgan inflammatory findings. Recognizing overflow diarrhea is critical to avoid inappropriate anti-motility therapy, which carries a high risk of colonic perforation in the setting of SC. Early cross-sectional imaging and prioritization of reversible causes are essential when managing such complex, multisystem presentations.