Stercoral colitis is an underrecognized, life-threatening complication of refractory constipation. We systematically reviewed Embase, PubMed/MEDLINE, Web of Science, and CINAHL for presentation, imaging, management, and outcomes. Fifty-three studies (58 patients) met inclusion. Mean age was 55.8 years (range 9–94); 62.1% were female. Chronic constipation (75.9%) and opioid exposure (13.8%) were common. CT was used in 86.2%, showing fecaloma and wall thickening (65.5%); perforation occurred in 29.3% and ischemic colitis in 44.8%. Conservative measures, manual disimpaction, enemas, laxatives, were common; endoscopic disimpaction was rare; surgery was reserved for deterioration, peritonitis, or perforation. Overall in-hospital/30-day mortality was 22.4% (operative 26.9% vs non-operative 0.0%). SC should be suspected in at-risk patients with refractory constipation; only 75.9% had abdominal pain, so its absence does not exclude disease. Early CT, especially with elevated WBC, CRP, or lactate, and severity-guided escalation to conservative therapy or timely surgery are essential; standardized criteria and prospective studies are needed.