Stercoral Colonic Perforation: A Rare but Serious Complication of GLP-1 Receptor Agonist–Induced Constipation

Introduction

Glucagon-like peptide-1 (GLP-1) receptor agonists are widely used for obesity and type 2 diabetes. Though generally well tolerated, gastrointestinal effects, including constipation, are common. Severe constipation leading to fecal impaction and stercoral colonic perforation is exceedingly rare but carries significant morbidity and mortality. We present a case of stercoral perforation of the transverse colon associated with long-term semaglutide therapy.

Case Presentation

A 30-year-old woman with postural orthostatic tachycardia syndrome (POTS), heterozygous factor V Leiden mutation (not anticoagulated), endometriosis, and class I obesity treated with semaglutide presented with two days of severe intermittent epigastric pain, nausea, and vomiting with occasional blood-streaked emesis, along with progressive constipation and hard, pebble-like stools. Labs showed leukocytosis of 17.4 × 10⁹/L with a left shift. CT of the abdomen and pelvis revealed marked fecal impaction of the ascending and transverse colon with pericolonic fat stranding adjacent to the distal transverse colon, raising concern for an underlying stricture.

Despite aggressive medical management with polyethylene glycol, Gastrografin enemas, and antiemetics, her pain worsened and she developed overflow diarrhea. Repeat CT on hospital day four showed pneumatosis and findings concerning for distal transverse colonic perforation with a possible colojejunal fistula. She underwent emergent exploratory laparotomy with partial transverse colectomy and primary anastomosis. Operative findings confirmed stercoral perforation from pressure necrosis caused by a large fecal bezoar, without fistula or malignancy. Her postoperative course was complicated by ileus, and limited antibiotic options due to multiple drug allergies necessitated empiric meropenem. She recovered and was discharged with plans for outpatient colonoscopy to exclude underlying colonic pathology.

Discussion

Stercoral perforation results from prolonged pressure of impacted fecal material on the colonic wall, causing ischemia, necrosis, and eventual perforation. GLP-1 receptor agonists slow gastrointestinal motility and are associated with constipation, which may predispose susceptible patients to fecal impaction. In this patient, chronic semaglutide use likely impaired colonic transit and promoted stool accumulation, culminating in stercoral perforation. As GLP-1 receptor agonist use expands, clinicians should maintain a high index of suspicion for severe constipation and impaction-related complications in patients with persistent abdominal pain, refractory constipation, or symptoms worsening despite standard bowel regimens. Early recognition and intervention may prevent progression to bowel ischemia and perforation, potentially avoiding emergent surgery.

Conclusion

This case highlights stercoral colonic perforation as a rare but serious complication of GLP-1 receptor agonist–associated constipation. Increased awareness of severe gastrointestinal adverse effects is essential as these medications become more widely prescribed for both diabetes and weight management.