Hard Diagnoses, Hard Conversations

Hard Diagnoses, Hard Conversations

Stercoral colitis is fecal impaction with pressure ischemia, ulceration, and possible perforation, and CT—not plain films—makes the diagnosis. Separately, end-of-life conversations in the ED depend less on time than on presence, plain language, and honest uncertainty. Stercoral Colitis Recognition and Management Pressure ischemia mechanism: Stercoral colitis is an inflammatory colonic injury from impacted stool raising intraluminal pressure, with the rectosigmoid antimesenteric border especially vulnerable because of narrow lumen and watershed blood supply. High-risk patient profile: Think of it in older, immobile patients with chronic constipation or constipating medications such as opioids, antipsychotics, and calcium channel blockers, even when the complaint is just vague weakness or urinary symptoms. CT-based diagnostic anchor: CT abdomen and pelvis with IV contrast is the gold standard, with severe disease flagged by pneumoperitoneum, pneumatosis, extraluminal stool, or pericolonic abscess. We get into the imaging severity distinctions in the episode. Limited value of plain films: Abdominal radiographs do not reliably diagnose or exclude stercoral colitis; their main bedside role is looking for free air when the patient is too unstable for CT. ED treatment priorities: Initial management starts with digital disimpaction, then enemas and an oral bowel regimen, while avoiding opioids and correcting fluids and electrolytes rather than waiting for inpatient care. Early surgery and admission: Perforation carries mortality as high as 60%, which is why surgical consultation and inpatient admission are reasonable for essentially all confirmed cases, not just the obviously sick ones. End-of-Life Conversations in the ED Presence over duration: A grounded 3 to 5 minute conversation often helps more than a longer detached one; sitting down at eye level and avoiding doorway updates changes how families experience the news. Plain language storytelling: Families process bad news better when you briefly tell the sequence of events in simple nonmedical terms—what happened before arrival, what was done, and what comes next or why it cannot. Honest uncertainty: Saying "I don't know" is often more trustworthy than speculation when prognosis or mechanism is unclear, especially after arrest or during rapidly evolving critical illness. Reducing inappropriate guilt: When families fixate on what they missed, a key move is to say plainly that they are not responsible and that some catastrophes are not predictable or preventable. Chaplains as team support: Chaplains extend care after death by staying with families, repeating information once shock sets in, and helping with rituals, viewing, and cultural needs while the ED keeps moving. Brief transition rituals: A five-minute pause before and after shift can create emotional containment for difficult cases and help separate resuscitation work from home life. We talk through what that looks like in the chapter.