Fecal impaction: Difference between revisions
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==Background== | ==Background== | ||
[[File:Rectum anatomy en.png|thumb|Anatomy of the anus and rectum.]] | [[File:Rectum anatomy en.png|thumb|Anatomy of the anus and rectum.]] | ||
*Typically a complication of chronic constipation that results in the accumulation hardened fecal matter in the colon or rectum that cannot be spontaneously evacuated | *Typically a complication of chronic constipation that results in the accumulation of hardened/inspissated fecal matter in the colon or rectum that cannot be spontaneously evacuated | ||
*Incidence greatly increases with age and polypharmacy; common in the inpatient or institutionalized setting | |||
===Risk Factors=== | ===Risk Factors=== | ||
*Elderly and young age | *Elderly and young age | ||
*Chronic [[constipation]] | *Chronic [[constipation]] | ||
*Lifestyle factors (immobility, low fiber diet, dehydration) | *Lifestyle factors (immobility/bedbound, low fiber diet, dehydration) | ||
*Medications that impair GI motility ([[anticholinergics]], [[antipsychotics]], [[opioids]]) | *Medications that impair GI motility ([[anticholinergics]], [[antipsychotics]], [[opioids]]) | ||
*Metabolic disorders ([[hypothyroidism]], [[Diabetes]] | |||
*Anatomic abnormalities ([[colorectal cancer|malignancy]], [[anorectal disorders|anorectal disease]], [[Hirschsprung's disease]]) | *Anatomic abnormalities ([[colorectal cancer|malignancy]], [[anorectal disorders|anorectal disease]], [[Hirschsprung's disease]]) | ||
*Neurologic conditions ([[dementia]], [[spinal cord injury]], [[cerebral palsy]]) | *Neurologic conditions ([[dementia]], [[spinal cord injury]], [[cerebral palsy]]) | ||
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==Clinical Features== | ==Clinical Features== | ||
===History=== | ===History=== | ||
*[[Abdominal pain]] or | *[[Abdominal pain]], bloating, distention, or early satiety | ||
*[[Nausea and vomiting]] | *[[Nausea and vomiting]] | ||
*Overflow stool incontinence as diarrhea | |||
*Obstipation | *Obstipation | ||
*[[Agitation]]/[[confusion]] (elderly patients with neuropsychiatric conditions) | *[[Agitation]]/[[confusion]] (elderly patients with neuropsychiatric conditions) | ||
*[[Tachycardia]] may be present due to pain or dehydration | |||
*[[Urinary incontinence]] | *[[Urinary incontinence]] | ||
===Physical exam=== | ===Physical exam=== | ||
*Abdominal distention and/or [[abdominal pain|tenderness]] | *Abdominal distention and/or [[abdominal pain|tenderness]] | ||
*Palpable firm stool balls on digital rectal exam | *Palpable firm stool balls or copious amounts of stool found on digital rectal exam | ||
**Note that for proximal impactions (proximal rectum or sigmoid colon), DRE may not be diagnostic | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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[[File:PMC5318312 12245 2017 134 Fig1 HTML.png|thumb|Pelvic CT scan showing a large fecal impaction (arrow).]] | [[File:PMC5318312 12245 2017 134 Fig1 HTML.png|thumb|Pelvic CT scan showing a large fecal impaction (arrow).]] | ||
*Digital rectal exam | *Digital rectal exam | ||
*Chemistry to evaluate for [[hypokalemia]] or [[ | *CBC | ||
*Chemistry to evaluate for [[hypokalemia]], [[hypercalcemia]], or prerenal [[acute kidney injury]] | |||
*Lacate, depending on abdominal exam | |||
*TSH if indicated | *TSH if indicated | ||
*[[Abdominal X-ray]] to evaluate for air-fluid levels and free-air | *[[Abdominal X-ray]] to evaluate for air-fluid levels and free-air | ||
*CT if severe presentation | *CT if severe presentation | ||
**CT may show large stool burden in colon/rectum | |||
**[[Stercoral colitis]] is CT finding caused by impacted fecal material causing pressure edema and ischemia on the bowel wall. Left untreated, the condition can lead to wall ischemia, ulceration, and perforation.<ref> Ünal E, Onur MR, Balcı S, Görmez A, Akpınar E, Böge M. Stercoral colitis: diagnostic value of CT findings. Diagn Interv Radiol. 2017;23(1):5-9.</ref> | **[[Stercoral colitis]] is CT finding caused by impacted fecal material causing pressure edema and ischemia on the bowel wall. Left untreated, the condition can lead to wall ischemia, ulceration, and perforation.<ref> Ünal E, Onur MR, Balcı S, Görmez A, Akpınar E, Böge M. Stercoral colitis: diagnostic value of CT findings. Diagn Interv Radiol. 2017;23(1):5-9.</ref> | ||
***Findings include colonic wall thickening, pericolonic fat stranding, and extraluminal bubbles of gas or abscess (signs of perforation); all of which are not found in uncomplicated fecal impaction. | ***Findings include colonic wall thickening, pericolonic fat stranding, and extraluminal bubbles of gas or abscess (signs of perforation); all of which are not found in uncomplicated fecal impaction. | ||
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==Management== | ==Management== | ||
*Surgery if there are signs of perforation, peritonitis, or stercoral colitis | *Surgery if there are signs of perforation, peritonitis, or stercoral colitis | ||
*Distal impactions - manual disimpaction and/or rectal suppositories or enemas | **In severe cases refractory to mainstay treatments, manual disimpaction under anesthesia in OR may be requried<ref>Setya A, Mathew G, Cagir B. Fecal Impaction. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.</ref> | ||
*Distal impactions - manual disimpaction and/or rectal suppositories or enemas (Fleet, mineral oil, warm water, docusate) | |||
**Administration of small-volume enemas over a longer time may be more beneficial and comfortable for patient | |||
**In small studies, Fleet (sodium phosphate) enemas led to to increased rate of electrolyte derangements in the elderly<ref>Ori Y, Rozen-Zvi B, Chagnac A, Herman M, Zingerman B, Atar E, Gafter U, Korzets A. Fatalities and severe metabolic disorders associated with the use of sodium phosphate enemas: a single center's experience. Arch Intern Med. 2012 Feb 13;172(3):263-5. doi: 10.1001/archinternmed.2011.694. PMID: 22332159.</ref> | |||
*Proximal impactions typically respond better to oral laxatives | *Proximal impactions typically respond better to oral laxatives | ||
*After initial disimpaction, address risk factors and initiate a maintenance bowel regimen | *After initial disimpaction, address risk factors (especially medications) and initiate a maintenance bowel regimen | ||
==Disposition== | ==Disposition== | ||
*Consider admission for patients with [[stercoral colitis]] for aggressive bowel regimen and washout | *Consider admission for patients with [[stercoral colitis]] for aggressive bowel regimen and washout | ||
*First-time fecal impaction may prompt colonoscopy or flexible sigmoidoscopy to assess for anatomic causes<ref>Obokhare I. Fecal impaction: a cause for concern? Clin Colon Rectal Surg. 2012 Mar;25(1):53-8. doi: 10.1055/s-0032-1301760. PMID: 23449376; PMCID: PMC3348734.</ref> | |||
==See Also== | ==See Also== | ||
Revision as of 16:11, 1 February 2024
Background
- Typically a complication of chronic constipation that results in the accumulation of hardened/inspissated fecal matter in the colon or rectum that cannot be spontaneously evacuated
- Incidence greatly increases with age and polypharmacy; common in the inpatient or institutionalized setting
Risk Factors
- Elderly and young age
- Chronic constipation
- Lifestyle factors (immobility/bedbound, low fiber diet, dehydration)
- Medications that impair GI motility (anticholinergics, antipsychotics, opioids)
- Metabolic disorders (hypothyroidism, Diabetes
- Anatomic abnormalities (malignancy, anorectal disease, Hirschsprung's disease)
- Neurologic conditions (dementia, spinal cord injury, cerebral palsy)
Clinical Features
History
- Abdominal pain, bloating, distention, or early satiety
- Nausea and vomiting
- Overflow stool incontinence as diarrhea
- Obstipation
- Agitation/confusion (elderly patients with neuropsychiatric conditions)
- Tachycardia may be present due to pain or dehydration
- Urinary incontinence
Physical exam
- Abdominal distention and/or tenderness
- Palpable firm stool balls or copious amounts of stool found on digital rectal exam
- Note that for proximal impactions (proximal rectum or sigmoid colon), DRE may not be diagnostic
Differential Diagnosis
Constipation
- Behavioral-related
- Lack of exercise
- Diet-related
- Fecal impaction
- Ileus from surgical abdomen
- Bowel obstruction
- Small bowel obstruction
- Large bowel obstruction
- Malignant bowel obstruction
- Specific causes: tumor, stricture, hernia, adhesion, volvulus
- Painful anorectal disorders (e.g. anal fissure, hemorrhoids)
- Medical causes
- Hypothyroidism
- Electrolytes
- Hypokalemia
- Medication-related
- Opiods, antipsychotics, anticholinergics, antacid, antihistamines
- Constipation (peds)
Evaluation
- Digital rectal exam
- CBC
- Chemistry to evaluate for hypokalemia, hypercalcemia, or prerenal acute kidney injury
- Lacate, depending on abdominal exam
- TSH if indicated
- Abdominal X-ray to evaluate for air-fluid levels and free-air
- CT if severe presentation
- CT may show large stool burden in colon/rectum
- Stercoral colitis is CT finding caused by impacted fecal material causing pressure edema and ischemia on the bowel wall. Left untreated, the condition can lead to wall ischemia, ulceration, and perforation.[1]
- Findings include colonic wall thickening, pericolonic fat stranding, and extraluminal bubbles of gas or abscess (signs of perforation); all of which are not found in uncomplicated fecal impaction.
Management
- Surgery if there are signs of perforation, peritonitis, or stercoral colitis
- In severe cases refractory to mainstay treatments, manual disimpaction under anesthesia in OR may be requried[2]
- Distal impactions - manual disimpaction and/or rectal suppositories or enemas (Fleet, mineral oil, warm water, docusate)
- Administration of small-volume enemas over a longer time may be more beneficial and comfortable for patient
- In small studies, Fleet (sodium phosphate) enemas led to to increased rate of electrolyte derangements in the elderly[3]
- Proximal impactions typically respond better to oral laxatives
- After initial disimpaction, address risk factors (especially medications) and initiate a maintenance bowel regimen
Disposition
- Consider admission for patients with stercoral colitis for aggressive bowel regimen and washout
- First-time fecal impaction may prompt colonoscopy or flexible sigmoidoscopy to assess for anatomic causes[4]
See Also
References
- ↑ Ünal E, Onur MR, Balcı S, Görmez A, Akpınar E, Böge M. Stercoral colitis: diagnostic value of CT findings. Diagn Interv Radiol. 2017;23(1):5-9.
- ↑ Setya A, Mathew G, Cagir B. Fecal Impaction. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
- ↑ Ori Y, Rozen-Zvi B, Chagnac A, Herman M, Zingerman B, Atar E, Gafter U, Korzets A. Fatalities and severe metabolic disorders associated with the use of sodium phosphate enemas: a single center's experience. Arch Intern Med. 2012 Feb 13;172(3):263-5. doi: 10.1001/archinternmed.2011.694. PMID: 22332159.
- ↑ Obokhare I. Fecal impaction: a cause for concern? Clin Colon Rectal Surg. 2012 Mar;25(1):53-8. doi: 10.1055/s-0032-1301760. PMID: 23449376; PMCID: PMC3348734.