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Fecal Impaction

Fecal impaction (FI) is a term referring to a particular condition of the digestive system, in which a immobile mass of feces develops in the rectum after the occurrence of a chronic conspitation.


Presentation

The main signs of FI include abnormal bloating, pain in defecation, rectal bleeding, spurious diarrhea and low back pain, which might be integrated by secondary signs such as feeling of incomplete evacuation, digital extraction, tenesmus, and enema retention. These symptoms may sometime be followed by vomiting and unexplained weight loss, both of them suggestive of a particularly alarming situation.

Fi in particular, but conspitation in general, presents a marked tendency to be underestimated due to the behaviors of patients, who are not always willing to discuss the details of private matters. Therefore, it is necessary to perform a clinical history of the patients in a gentle manner, to obtain as much information regarding the patient’s privacy as possible. The first questions to do regard the hardness of the stools, the frequency of defecation and the presence of strain while defecating. Particularly illuminating might also be questions pertaining the time spent while waiting to defecate and the maneuvers performed, which can reveal the presence of a laxative abuse or a colonic outlet obstruction, or the questions pertaining the duration of the problem, which could underline the presence of congenital conditions.

Most important are also the questions regarding the daily life, especially those concerning the diet and the physical activity of the patient, to see if patients consume too little fiber or too little water and if they assume large quantities of products with clear diuretic effect such as coffee, tea, alcohol or milk. Such diuretic effects can also be induced by many medications, like narcotics or antipsychotic agents, or by physical activity, as movements stimulate bowel mobility.

Gangrene
  • A case of extensive gangrene of the colon secondary to fecal impaction is reported. The role of ischemia in the management of colonic obstruction and the pathogenesis and treatment of colonic gangrene are discussed.[ncbi.nlm.nih.gov]
  • The mortality rate is still 50% when bowel gangrene develops.[ncbi.nlm.nih.gov]
Amyloidosis
  • Specific diseases or conditions, such as irritable bowel syndrome , neurological disorders , diabetes , and autoimmune diseases such as amyloidosis , celiac disease , lupus , and scleroderma can cause constipation.[en.wikipedia.org]
  • The disorders concerned certainly include bowel syndromes, as well as a number of neurological disorders, diabetes and even autoimmune diseases such as amyloidosis, celiac disease, and cystic fibrosis.[symptoma.com]
Hypoxemia
  • Cardiopulmonary arrest in childhood is usually due to respiratory failure leading to hypoxemia, acidosis, cardiac dysfunction, and terminal asystole.[ncbi.nlm.nih.gov]
Constipation
  • Constipation is a significant problem in the long-term care patient. There is a high prevalence of both primary and secondary causes of constipation in this population.[ncbi.nlm.nih.gov]
  • Controlled constipation (OR: 9.8 [5.2-18.4]) and uncontrolled constipation (OR: 37.21 [19.7-70.1]), the number of medications (OR: 1.2 [1.1-1.3]), reduced functional capacity (OR: 0.98 [0.97-0.99]) and the occasional use of NSAIDs were independent risk[ncbi.nlm.nih.gov]
  • These preparations constitute the most efficacious osmotic laxatives (more than lactulose) and are the first-line treatment for functional constipation in the short and long-term.[ncbi.nlm.nih.gov]
  • […] given medications to prevent constipation before it occurs.[en.wikipedia.org]
  • An 8-year-old girl presented with frequent, nonfebrile, urinary tract infections and a lifelong history of severe constipation.[ncbi.nlm.nih.gov]
Abdominal Bloating
  • bloating abdominal pain and cramping straining when trying to pass stools; feeling the need to push nausea vomiting headache unexplained weight loss weak appetite hardened areas or masses in the abdomen Symptoms of severe fecal impaction include: rapid[diagnose-me.com]
  • The following fecal impaction symptoms reflect what some people go through: Abdominal discomfort Abdominal bloating Abdominal pain Leakage of liquid stool Feeling like you need to push Nausea and vomiting Weight loss due to lack of appetite Headaches[belmarrahealth.com]

Workup

The most important laboratory studies for the workup of fecal impaction include complete blood count, leukocyte count, thyroid function tests (for the patients refractory to dietary management), and serum electrolyte profile (potassium, calcium, glucose or creatinine). However, this approach does not play an important role in the FI assessment.

Conversely, imaging studies are particularly important, since they can rule out sepsis or intraabdominal complications as sources of abdominal pain and of the other severe signs of FI. The imaging techniques allow to precisely localize the fecal mass and its dimensions and differentiate fecal impaction from bowel obstruction and other types of constipation. Imaging studies can also be integrated with computed tomography, to further evaluate the abdominal complication with more details.

Other useful clinical techniques used to assess FI include:

  • Barium or gastrografin study, particularly useful to assess the presence of an obstructing colon cancer, colonic strictures, or intermittent volvulus.
  • Defecography, which should be carried out when an obstruction at the level of the anal canal is suspected.
  • Colonic transit study, performed when the clinician suspects the presence of a colonic mobility disorder.
  • Lower GI endoscopy, performed when an empty rectal vault and a distended proximal colon suggest the presence of a large bowel obstruction.
  • Anorectal manometry, used to measure parameters such as external anal sphincter, puborectalis function, reflex relaxation of the internal sphincter, anorectal pressure, and the threshold after which rectal distension is perceived.

Other possible clinical procedures include fluoroscopic rectal imaging [8] (to identify idiopathic megacolon even with no organic causes of other related problems), balloon expulsion, anoscopy and rectal biopsy.

Treatment

The treatment of fecal impaction is based on two important points: to treat the impaction itself and avoid future cases of recurrence.

Three methods are the strategy to remedy the impaction: softening the stool mass, lubricating it or breaking it into small pieces which are much easier to remove. The stool can be softened by using osmotic laxatives, that increase the water content to help the fecal expulsion. Osmotic laxatives might also cause cramping and severe pain while the patient tries to evacuate the stool from the rectum, and that is the reason why they can sometime be replaced by other types of laxatives such as polyethylene glycol. These are not suited for the cases of emergence, where the fecal impaction causes severe pain and requires immediate expulsion, as they might need several hours to take effect. In these situations, it is appropriate to use enemas, which not only increases the water content but also stimulates peristalsis to facilitate the expulsion.

If enemas is not successful at dislodging the impacted stool, which still remains too large and dry to be effectively expelled through the anus, the clinician can use mineral oils to lubricate the fecal mass and make its passage through the rectum and anus easier. In the most severe cases, where even lubrication turns out to be ineffective, manual disimpaction might be performed. After lubricating the anus, the clinician proceeds to break up the stool mass with a gloved finger or an appropriate tool, with or without general anaesthesia, and if even this appears to be ineffective a surgical procedure might be performed.

The individuals who have already experienced a case of fecal impaction are at high risk to experience another one in the future. Therefore, prevention for these patients is paramount. Preventive measures involve first of all changes in the daily life of the subjects, that should follow a fiber-rich diet, increase the daily water intake, practice physical activities on a daily bases and make sure they regularly defecate each morning to guarantee a regular fecal evacuation of the rectum. It should be remembered that many medications, such as opioids, can reduce colon mobility and cause consultation, and stimulant laxatives might cause dependence by changing the normal colon function [9]. Therefore, the use of these products should constantly be monitored by the physician and be integrated with other ones to reduce as much as possible the risk of side effects.

Prognosis

If the medical and dietary management is strictly followed, usually patients recover successfully in a relatively short period of time, and no recurrence should occur if they keep complying with the therapy. In the cases in which surgical procedure is needed, the patients positively respond to the treatment, experiencing a great improvement in the quality of life.
The most difficult patients to treat are those who are chronically dependent on increasing doses of laxatives. These subjects have to be treated with a therapy based on the combination of fiber, water, and osmotic agents (like sorbitol and glycol). However, in rare occasions the patients might become virtually refractory to laxatives, and this requires the execution of an abdominal colectomy.

Etiology

The common causes of fecal impaction are physical inactivity, low water intake and certain types of diets, particularly those poor in fibers [2] [3]. But some kind of medications can also directly or indirectly induce FI, and these include opioid pain relievers (like oxycodone, hydrocodone and methadone), diuretics, anticonvulsants and many types of sedatives which are able of reducing bowel movement, causing the feces to become too large, hard or dry to be expelled [4].

FI can also be caused by a series of physiological disorders as adverse side effect. The disorders concerned certainly include bowel syndromes, as well as a number of neurological disorders, diabetes and even autoimmune diseases such as amyloidosis, celiac disease, and cystic fibrosis [5]. In less frequent cases, FI can also come as a consequence of a increased level of blood calcium.

Epidemiology

According to the data coming from recent surveys, FI is one of the most common digestive complications in the United States, where it occurs in a population range going from 2% to 20% [6]. Because of its frequency, FI has a huge impact upon society, responsible for 3% of clinical visits in outpatient clinics, with an annual healthcare costs of around 6.9 billions of dollars [5] and 725 millions spent in laxative products annually [6]. Furthermore, FI appears to be more frequent in women than men and in elder people rather than young ones. The reason for this age-related trend might be due to the increased number of physical complications appearing in advanced ages of life, as well as the consequent decreased level of physical activity [7].

Sex distribution
Age distribution

Pathophysiology

Fecal impaction may appear as the consequence of stool consistency related issues or defecatory behavior related ones. Although very frequent when the patient shows hard and dry stool, FI can also manifest itself with the presence of soft bulky stool, particularly when the subject is affected by anatomical abnormalities or impaired colorectal motility. The site involved is the already mentioned rectum, which might completely be filled by a large fecal mass, sometimes of relatively huge sizes (several tens of centimeters in length and in width). As previously observed, such large mass hinders or blocks the evacuation of excreta.

Prevention

The prevention of FI is based on the drastic reduction of the factors causing the impaction itself. This means to reduce the use of opioid-based medications, at least as much as possible according to the patient’s needs and the nature of the drug, obviously remembering that any change in the prescription should be performed under the constant supervision of the physician. But this also means to ensure an appropriate water intake, a fiber-rich diet and a constant physical exercise.

Summary

Fecal impaction (FI) is also referred to as fecal loading, a term which indicates a large volume of stool that hinders the passage of feces regardless its consistency [1]. This condition can easily turn in bowel obstruction, when the fecal mass entirely blocks excreta, and when this stage occurs, FI might become life-threatening if left untreated. The common adverse effects of FI include abdominal pain, diarrhea, headache and excessive gas discharge.

Patient Information

Fecal impaction (FI) is a term referring to a particular condition of the digestive system, in which a immobile mass of feces develops in the rectum after the occurrence of a chronic conspitation. This condition is also referred to as fecal loading, to indicate a large volume of stool that hinders the passage of feces regardless its consistency. This can easily turn in bowel obstruction, when the fecal mass entirely blocks it, and when this stage occurs, FI might become life-threatening if left untreated.

The common causes of IF are physical inactivity, low water intake and certain types of diets, particularly those poor in fibers. But some kind of medications can also directly or indirectly induce FI, and these include opioid pain relievers, diuretics, anticonvulsants and many types of sedatives which are able of reducing bowel movement, causing the feces to become too large, hard or dry to be expelled.

The main signs of FI include abnormal bloating, pain in defecation, bleeding from the anus, and low back pain. These symptoms might sometime be followed by vomiting and unexplained weight loss

There are three main strategies to treat fecal impaction: softening the stool mass, lubricating it or breaking it into small pieces which are much easier to remove. This can be achieved by using osmotic laxatives, enemas and mineral oils. In the most severe cases, the fecal impaction can be remedied by annually removing the fecal mass with a gloved finger or by performing a surgical procedure.

If the medical and dietary management is strictly followed, usually patients recover successfully in a relatively short period of time, and no recurrence should occur if they keep complying with the therapy. In the cases in which surgical procedure is needed, the patients positively respond to the treatment, experiencing a great improvement in the quality of life. FI can be avoid by avoiding the factors responsible to it, which means to reduce the use of opioid-based medications, increase the water supply, follow a fiber-rich diet and perform a regular physical exercise.

References

Article

  1. National Collaborating Centre for Acute Care. Faecal incontinence the management of faecal incontinence in adults. London: National Collaborating Centre for Acute Care (UK) 2007.
  2. Walia R, Mahajan L, Steffen R. Recent advances in chronic constipation. Curr Opin Pediatr 2009 21 (5): 661–6.
  3. McCallum IJ, Ong S, Mercer-Jones M. Chronic constipation in adults. BMJ 2009 338: b831.
  4. Selby W, Corte C. Managing constipation in adults". Australian Prescriber 33 (4): 116–9. Retrieved 27 August 2010.
  5. Locke GR, Pemberton JH, Phillips SF. American Gastroenterological Association Medical Position Statement: guidelines on constipation. Gastroenterology 2000 119 (6): 1761–6.
  6. Sonnenberg A, Koch TR. Epidemiology of constipation in the United States. Dis Colon Rectum 1989 32 (1): 1–8.
  7. Hsieh C. Treatment of constipation in older adults. Am Fam Physician 72 (11): 2277–84.
  8. Gladman MA, Knowles CH. Novel concepts in the diagnosis, pathophysiology and management of idiopathic megabowel. Colorectal Dis. Jul 2008;10(6):531-8; discussion 538-40.
  9. Joo JS, Ehrenpreis ED, Gonzalez L et al. Alterations in colonic anatomy induced by chronic stimulant laxatives: the cathartic colon revisited. Journal of Clinical Gastroenterology 26 (4): 283–6.

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Last updated: 2018-06-22 09:31