Fecal impaction in adults.

ABSTRACT: Fecal impaction is a common digestive disorder and is considered an acute complication of chronic and untreated constipation. Generally, the factors responsible for fecal impaction are similar to those associated with constipation. Early identification and treatment minimize complications and patient discomfort. Common treatment options to address fecal impaction of the rectum include manual disimpaction or fragmentation, the use of distal and/or proximal softening or washout procedures such as enemas and suppositories, and oral or nasogastric tube placement for the administration of polyethylene glycol solutions containing electrolytes. In severe cases, surgical intervention is necessary. Post-treatment evaluation should include a colonic evaluation by flexible sigmoidoscopy, a colonoscopy, or a barium enema after the fecal impaction resolves. Following treatment, conduct an evaluation of causes and create a preventive therapy plan.

Stercoral Colitis in the Emergency Department: A Retrospective Review of Presentation, Management, and Outcomes.

STUDY OBJECTIVE: Stercoral colitis is inflammation of the bowel wall caused by fecal impaction. Despite reported high morbidity and risk of perforation, little research assessing outcomes is available. This study characterizes the presentation, management, and outcomes of emergency department patients with stercoral colitis. METHODS: We performed a retrospective chart review of ED patients with stercoral colitis identified on computed tomography (CT) scan. Of 814, 522 visits to multiple EDs across the US, 269 met the inclusion criteria. Variables regarding patient presentation, management, and outcomes were extracted from electronic medical records. Results were analyzed with percentages and 95% confidence intervals (CIs). RESULTS: Of 269 patients, the median age was 76 years. The most common chief concern was abdominal pain/distension (33.8%). However, abdominal pain was documented as absent in 62.1% of cases. The most common CT findings included fecal impaction (96.7%), bowel wall inflammation (72.9%), and fat stranding (48.3%). Eighty-four (31.2%) patients were discharged home from the ED, and over half of these (45/84, 53.6%) received no enema, laxatives, or disimpaction. Overall, 9 patients (3.3%, 95% CI 1.6% to 6.5%) required surgical management of a related complication within 3 months, 27 (10.0%, 95% CI 6.8% to 14.4%) returned to the ED within 72 hours, and 9 (3.3%, 95% CI 1.6% to 6.5%) died from a cause related to stercoral colitis within 3 months. CONCLUSION: Patients with stercoral colitis often present in a nonspecific manner, and short-term mortality is substantial. In this study, most discharged patients did not receive recommended treatment. This represents the largest ED study of stercoral colitis and provides further evidence linking this diagnosis with adverse outcomes.

Acupuncture for Anaemia and Large Intestine Impaction Associated with Hind Limb Weakness in a Horse: A Case Report.

A 24-year-old horse was presented with a clinical history of anaemia, large intestine impaction and hind limb weakness. Loss of body weight was also reported. Hematocrit and hemoglobin levels were low and piroplasmosis test was negative. Nasogastric intubation with laxative agents was performed and 50 ml of a red blood-cell-supplement was given daily during a month. An assessment following Traditional Chinese Veterinary Medicine (TCVM) principles was performed after the last episode of large intestine impaction. A swollen, pale and wet tongue was observed. A superficial, weak pulse combined punctually with a slippery pulse was detected on the right side. The pulse on the left side was very thin. BL18, BL20 and BL23 were the most sensitive acupoints on the right side. BL18 and BL23 were the most sensitive on the left. TCVM diagnosis was Qi/Yang Kidney Deficiency, Spleen Qi Deficiency with Stagnation and Blood Deficiency. It received acupuncture at Bai-Hui, KI3, KI7, KI10, BL23, GB39, ST36, BL17 and acupressure at SP10. The client reported a significant improvement after treatment and hematocrit and hemoglobin levels were normal. KI3, ST36, BL39 acupoints were treated 14 days later. The outcome was favourable and one acupuncture session per month was recommended. No previous case reports in equines have been documented with a combination of blood, gastrointestinal and musculoskeletal problems in the same episode. This case is an example of an integrative approach to investigate the origin and the interdependent relation between body systems.

Faecal impaction causing bilateral pelvic venous thrombosis.

INTRODUCTION: We present a first description of faecal impaction (FI) causing occlusion of the pelvic venous system, resulting in a bilateral thrombosis of the external iliac vein. PATIENTS AND METHODS: Our 76-year-old female patient was admitted with gradual swelling of both legs. Clinical evaluation revealed a painless abdominal distension and marked bilateral edema of the legs. A computed tomography (CT) scan showed gross dilatation of the colon and rectum, with FI. A short bilateral occlusion of the external iliac vein was seen, with thrombus in both pelvic veins. Doppler ultrasonography confirmed a thrombosis of the external iliac vein and common femoral vein on both sides. RESULTS: A conservative treatment consisting of manual evacuation, enema, laxatives and systemic anticoagulation was successfully applied. CONCLUSIONS: FI represents a common - yet preventable - health problem, mainly in the elderly. This case illustrates a rare complication of FI if left untreated.

Stercoral colitis complicated with ischemic colitis: a double-edge sword.

BACKGROUND: Stercoral colitis is a rare inflammatory process involving the colonic wall secondary to fecal impaction with high morbidity and mortality; especially if complicated with ischemic colitis, stercoral ulcer formation and subsequent perforation. There are several case reports published on abdominal perforation resulting from stercoral colitis. However, stercoral colitis complicated by ischemic colitis is rare. The purpose of this case report is to describe the potential challenges in the diagnosis and management of stercoral colitis with ischemic colitis. CASE PRESENTATION: An 87 years old male with history of chronic constipation presents with severe abdominal pain to the emergency department. The patient was hemodynamically stable. On physical examination, the abdomen was mildly distended with moderate tenderness. Lab work was significant for leukocytosis and lactic acidosis. Abdominal CT scan revealed large amount of retained stool in the colon, bowel wall thickening and infiltration of peri-colonic fat, which were suggestive for stercoral colitis. Patient was started on IV fluids and antibiotics. He was given an enema, followed by laxative and manual disimpaction of stool. Colonoscopy was performed and biopsies were obtained. Tissue biopsy was significant for focal active colitis with regenerative glandular changes and neural hyperplasia. CONCLUSION: Elevated lactic acid level secondary to ischemia of the bowel wall with CT scan findings aid in establishing the diagnosis of stercoral colitis complicated with ischemic colitis. Urgent treatment with laxatives and fecal disimpaction is indicated to prevent perforation and peritonitis.

Diagnostic approach to constipation impacts pediatric emergency department disposition.

OBJECTIVES: Constipation is a common cause of abdominal pain in children presenting to the emergency department (ED). The objectives of this study were to determine the diagnostic evaluation undertaken for constipation and to assess the association of the evaluation with final ED disposition. METHODS: A retrospective chart review of children presenting to the pediatric ED of a quaternary care children's hospital with abdominal pain that received a soap suds enema therapy. RESULTS: A total of 512 children were included, 270 (52.7%) were female, and the median age was 8.0 (IQR: 4.0-11.0). One hundred and thirty eight patients (27%) had a digital rectal exam (DRE), 120 (22.8%) had bloodwork performed, 218 (43%) had urinalysis obtained, 397 (77.5%) had abdominal radiographs, 120 (23.4%) had abdominal ultrasounds, and 18 (3.5%) had computed tomography scans. Children who had a DRE had a younger median age (6.0, IQR: 3.0-9.25 vs. 8.0, IQR: 4.0-12.0; p<0.001) and were significantly less likely to have radiologic imaging (OR=0.50, 95% CI 0.32-0.78; p=0.002), but did not have an increased odds of being discharged home. After adjusting for gender, ethnicity, and significant past medical history those with an abdominal radiograph were less likely to be discharged to home (aOR=0.56, 95% CI 0.31-1.01; p=0.05). CONCLUSIONS: The diagnostic evaluation of children diagnosed with fecal impaction in the ED varied. Abdominal imaging may be avoided if children receive a DRE. When children presenting to the ED with abdominal pain had an abdominal radiograph, they were more likely to be admitted.

Masa abdominal en un adolescente / Abdominal mass in an adolescent

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Soap Suds Enemas Are Efficacious and Safe for Treating Fecal Impaction in Children With Abdominal Pain.

OBJECTIVES: Constipation is a common cause of pediatric abdominal pain and emergency department (ED) presentation. Despite the high prevalence, there is a dearth of clinical information and wide practice variation in childhood constipation management in the ED. The objective of the study was to assess the efficacy and safety of soap suds enema (SSE) in the therapy for fecal impaction in children with abdominal pain within the pediatric ED setting. The primary outcome was stool output following SSE. Secondary outcomes were adverse events, admissions, and return visits within 72 hours. METHODS: The present study is a retrospective cross-sectional study performed in the ED at a quaternary care children's hospital of patients seen during a 12-month period who received an SSE for fecal impaction. RESULTS: Five hundred twelve patients (53% girls, median age 7.8 years, range: 8 months-23 years) received SSE therapy during a 1-year period. Successful therapy (bowel movement) following SSE occurred in 419 (82%). Adverse events included abdominal pain in 24 (5%) and nausea/vomiting in 18 (4%). No SSE-related serious adverse events were identified. Following SSE, 405 (79%) were subsequently discharged, of which 15 (3.7%) returned to the ED for re-evaluation within 72 hours. CONCLUSIONS: SSE is an efficacious and safe therapeutic option for the acute treatment of childhood fecal impaction in the ED setting.

Faecal impaction: in-hospital complications and their predictors in a retrospective study on 130 patients.

AIM: Faecal impaction may be a medical emergency. The frequency of complications of this condition and their predictors are not known. We determined the clinical presentation, the in-hospital complications and their predictors in 130 patients diagnosed with faecal impaction. METHOD: This was a retrospective study of the medical records of 130 patients who presented with faecal impaction to a tertiary care center in Beirut, Lebanon, between 1992 and 2009. The clinical outcome and complications were reviewed. The association between in-hospital complications and other variables was determined. RESULTS: The mean age of the patients was 67.1 years. Ninety-eight (75.3%) patients had at least one of the following: heart disease (36.3%), neurological disease (28.8%) or diabetes (22.6%), and 26.7% were bedridden. The site of impaction was the rectum in 66.4%. The patients were treated by manual disimpaction (34.5%), enema (89.1%) or oral laxatives (84.0%). A delay in treatment of more than 6 h occurred in 70 (53.8%) patients. In-hospital complications occurred in 34 (24.6%) patients, the most common of which were infectious (16 cases), systemic inflammatory response syndrome (16 cases), cardiopulmonary (14 cases) and death (one patient). Time to the start of treatment was longer in patients who developed complications compared with those who did not (10.1 h vs 7.1 h; P = 0.02). Patients > 80 years of age, or patients with heart or neurological disease were at a higher risk of developing complications (P = 0.03, P = 0.03 and P = 0.02, respectively). CONCLUSION: Treatment delay, increasing age and the presence of heart or neurological disease seem to be predictors of in-hospital complications in patients with faecal impaction.

From fecal impaction to colon perforation.

The authors present the case of an elderly, nonverbal nursing home resident with dementia who developed fecal impaction, despite interventions such as enema. Subsequent stercoral perforation of the sigmoid colon resulted in peritonitis, sepsis, and death. The authors discuss colon perforation as a result of fecal impaction, as well as the difficulties of pain assessment and communication in patients with dementia.

Recomendaciones para el tratamiento del estreñimiento funcional / Guidelines for the treatment of functional constipation

El estreñimiento es un problema clínico frecuente. Afecta del 2 al 30% de los niños, según el criterio diagnóstico utilizado. El tratamiento recomendado se basa en: a) explicación-desmitificación; b) desimpactación fecal y c) mantenimiento con cambios en la dieta, modificación de los hábitos higiénicos y el uso de laxantes. En la última década ha variado el sistema de vaciado intestinal; de la clásica vía rectal hemos pasado al uso generalizado de la vía oral a base de polietilenglicol 3350.Se debe tener en cuenta las necesidades individuales y las preferencias del paciente. El tratamiento de mantenimiento se iniciará inmediatamente después de lograr el vaciado intestinal. Está basado en la modificación de los hábitos dietéticos, higiénicos y en el uso de laxantes. Una adecuada ingesta de fibra y agua, el entrenamiento del hábito defecatorio y el uso de laxantes orales logra una defecación diaria y no dolorosa, evitando la reacumulación de heces. El uso de enemas puede ser efectivo para la desimpactación, pero tiene el riesgo de lesión traumática y no es adecuado para el tratamiento de mantenimiento. Los laxantes recomendados son los osmóticos. El tratamiento de primera elección en niños de cualquier edad es el polietilenglicol 3350 por su seguridad, efectividad y tolerancia. Su dosis varia entre 0,25 a 1,5g/kg. El mejor conocimiento de la fisiología de la defecación ha permitido el desarrollo de nuevos fármacos: bloqueantes de los receptores de la serotonina o activadores de los canales del cloro (AU)

Constipation is common in childhood. It can affect around 5–30% of the child population, depending on the criteria used for diagnosis. The currently recommended treatment is based on three main points: a) explanation, b) disimpaction and c) maintenance therapy consisting of diet changes, behavioural modification, and the use of laxatives. In the last decades treatment on disimpaction have changed radically from the rectal route to the oral route with polyethylene glycol 3350 (PEG), the most used and accepted regimen nowadays. Treatment and care should take into account the individual needs and preferences of the patient. Good communication is essential, to allow patients to reach informed decisions about their care. Maintenance therapy consists of dietary interventions, toilet training, and laxatives to obtain daily painless defaecation in order to prevent re-accumulation of stools. Maintenance therapy should be start as soon as the child's bowel is disimpacted. Early intervention with oral laxatives may improve complete resolution of functional constipation. Enemas using phosphate, mineral oil, or normal saline are effective in relieving rectal impaction, but carry the risk of mechanical trauma and are not recommended for maintenance therapy in the paediatric population. Among osmotic agents, polyethylene glycol 3350 plus electrolyte solutions appear to be the first-line drug treatment to use in children of any age, as it is safe, effective, and well-tolerated. Recommended doses ranges from 0.25 to 1.5g/kg. Advances in the understanding of the gastrointestinal enteric nervous system and epithelial function have led to the development of new substances that bind to serotonin receptors or are chloride channel activators (AU)

[Rational diagnostics of acute abdomen]. / Rationelle Diagnostik des "akuten Abdomens"

BACKGROUND: In view of the threat that comes with an acute abdomen, it is of major importance that diagnostics are executed quickly and efficiently. In the course of this two tendencies can be differentiated: 1) general use of complex examination (e.g. CT, MRT) of all potential patients and 2) step-by-step-diagnostics with advanced diagnostics as and when required. MATERIAL AND METHODS: A total of 444 patients with an acute abdomen as admission diagnosis were investigated. All data were evaluated prospectively and analyzed retrospectively. All patients had the same basic diagnostics consisting of aclinical history, clinical examination, laboratory examination, abdominal sonography and x-ray overview images. These examinations were supplemented when required by advanced measures, such as CT, colon enema with contrast fluid, endoscopic examination and diagnostic laparotomy. RESULTS: Three different disease groups of unequal diagnostic need could be identified. The first group, presented in the form of an appendicitis showed that in 80% of all patients a basic diagnosis was sufficient. Advanced examination such as CT affected 14%. The negative appendectomy rate amounted to 8%. Other diseases belonging to the first group were ileus, acute biliary diseases, perforation etc. In the second group presented in the form of a diverticulitis, an advanced radiological examination was required in 84% of all cases. Similar results are also expected in cases of pancreatitis. In the third group presented in the form of coprostasis, inflammatory etiology was found in 39% of all secondary diseases. However the symptoms became clinically apparent after treatment of the coprostasis. In this group a basic diagnosis was satisfactory in 84% of cases, however, a diagnostic laparotomy was inevitable for 3% of these patients. CONCLUSION: Generally step-by-step diagnostic approach has proven itself to be efficient. For 80% of all patients it makes advanced diagnostic measures unnecessary. The exceptions are diseases in which it is necessary to know not only the diagnosis but also the disease stage. In these cases (e.g. pancreatitis, diverticulitis etc.) advanced diagnostics should be pursued from the onset. The necessity of a diagnostic laparotomy has lost importance for 1% of all patients.

A patient with abdominal distension.

A 74-year-old woman was admitted to our hospital because of vomiting and abdominal pain. She had been well until 24 hours before admission, when she had had her last meal. She had not eaten anything unusual. She developed pain in the left lower abdominal quadrant, and difficulties with her bowel movements. An enema was given unsuccessfully. There was progressive distension of the abdomen. The patient started to vomit gastric and later bilious contents. No history of abdominal symptoms or weight loss was reported. She currently takes oral antidiabetic agents and an angiotensin II blocker because of hypertension. On physical examination she was not in distress and was afebrile, blood pressure 130/100 mmHg, pulse rate 88 beats/min. On auscultation increased bowel sounds with rushes of high-pitched sounds were heard. Her abdomen was distended and a large tender mass filling the whole left lower quadrant without signs of peritoneal irritation was found. There were no faeces on rectal examination. The leucocyte count was 10.2 mmol/L, haemoglobin 7.2 mmol/L, C-reactive protein 36 mg/l and lactate dehydrogenase 535 U/l. Under suspicion of a mechanical bowel obstruction without signs of peritonitis, the patient was treated with a nasogastric tube, fasting and enemas on which she improved. An abdominal X-ray in bed taken on day two showed no bowel distension (figure 1). After removing the nasogastric tube on day two the nausea returned. Abdominal examination was unchanged. An abdominal computed tomography (CT) scan after drinking oral contrast and intravenous contrast was performed (figure 2).

Management of functional constipation in childhood.

Functional constipation is a common condition. In the majority of cases the constipation develops as a result of a complex weave of factors including specific triggers, e.g. reduced fluid intake following a viral infection or periods of restricted access to the toilet. The passage of large painful stools perpetuates the problem when the child begins to associate pain with defecation. The management of constipation can often be a challenge in children, who initially may be reluctant to sit on the toilet. This article will discuss the contributory factors to the cause of constipation and identify the keys to successful treatment, including ensuring a holistic child-focused approach with effective initial evacuation and appropriate maintenance therapy.

Fecal incontinence in elderly patients: common, treatable, yet often undiagnosed.

It is important for primary care physicians to take fecal incontinence seriously and not dismiss it as a normal part of aging. Elderly patients may be reluctant to admit fecal incontinence, so clinicians need to ask about it. Two of the most common causes are fecal impaction (especially in nursing home patients) and rectosphincter dysfunction in people with diabetes.

Bilateral hydronephrosis due to fecaloma in an elderly woman.

By computer search of the literature, we found few cases of hydronephrosis due to fecal impaction. Because such a complication is extremely rare, we describe an 81-year-old woman with dementia, gallstones, arterial hypertension, and diverticulosis of the sigma who was hospitalized for severe constipation, fecaloma, and bilateral hydronephrosis. Through simultaneous lavage by two rectal tubes and manual disimpaction of fecaloma, bilateral hydronephrosis was resolved. We also briefly review the appropriate literature.