Stercoral colitis is a rare but potentially life-threatening condition resulting from chronic constipation and fecal impaction, most often affecting patients with neurologic impairment. We report the case of a 50-year-old paraplegic man with a history of spinal cord injury who developed autonomic dysreflexia and septic shock secondary to a perforated stercoral ulcer within an end colostomy. The patient was admitted for sacral wound reconstruction and initially showed no signs of infection. On postoperative day 3, he decompensated, and imaging revealed pneumoperitoneum and a large fecal burden. Emergent laparotomy identified a stercoral perforation at the colostomy site, and surgical revision of the colostomy was performed. This case illustrates a rare presentation of stercoral perforation in a neurologically compromised patient with a colostomy. Clinicians should maintain a high index of suspicion for stercoral ulceration in patients with spinal cord injury and emphasize preventive bowel care, close monitoring, and timely imaging to reduce morbidity and mortality.

Enterocutaneous fistulas (ECFs) are abnormal connections between epithelium of the intestinal lumen and skin. The diagnosis and characterization of an ECF is vital to determine the appropriate treatment approach. Diagnosis of ECFs are typically made by visualization of succus drainage from a surgical incision. However, when diagnosis is unclear, various radiological modalities are available to aid diagnosis. We report a case of incidental application of nuclear medicine hepatobiliary iminodiacetic acid scan which led to the diagnosis of an ECF.