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.

• Pain

  Symptoms of fecal impaction extend from constipation, anorexia, nausea, vomiting and abdominal pain, to full blown sepsis. [ncbi.nlm.nih.gov]

  Clinical History 66 Y.O. female with abdominal pain and vomiting for 15 days. Known case CRF. Palpable mass on PR. Imaging Findings 66 Y.O. female presented with abdominal pain and vomiting for 15 days. There is palpable mass on PR. [eurorad.org]

  Successful rectal disimpaction, defecation and fecal incontinence frequencies, occurrence of abdominal pain and watery stools, CTTs (before and after disimpaction), and behavior scores were assessed. [pediatrics.aappublications.org]

• Weight Loss

  Clinical manifestations include fecal incontinence, abdominal distention and pain, anorexia, weight loss, intestinal obstruction, and stercoral ulceration with bleeding or colonic perforation. [ncbi.nlm.nih.gov]

  loss in obese adolescents. [link.springer.com]

  Anorexia (avoiding eating), unexplained weight loss and headaches. Rapid heart rate. Hyperventilation, fever or confusion. Dehydration or incontinence. [myphysiciansnow.com]

  These symptoms may sometime be followed by vomiting and unexplained weight loss, both of them suggestive of a particularly alarming situation. [symptoma.com]

  loss weak appetite hardened areas or masses in the abdomen Symptoms of severe fecal impaction include: rapid heart rate dehydration rapid breathing fever confusion easily becoming agitated bladder pressure urinary incontinence rectal bleeding blood in [diagnose-me.com]

• Weakness

  Older people may develop constipation and fecal impaction due to reduced mobility and weak abdominal muscles. [everydayhealth.com]

  The rectosigmoid colon dilates to accommodate the mass, which, in turn, is not pliable enough to pass through the disproportionately small anal canal by the patient's weak defecation effort. [eurorad.org]

  During this procedure, the patient should be checked regularly to assure that there are no untoward effects such as weakness, diaphoresis or clamminess, or changes in pulse rate. [encyclopedia.com]

  In some patients, this may contribute to sphincter weakness. This damage may contribute to the incontinence experienced by patients with a dilated rectum. [doi.org]

• Sepsis

  Subsequent stercoral perforation of the sigmoid colon resulted in peritonitis, sepsis, and death. [ncbi.nlm.nih.gov]

  […] bowel sores Complications of fecal impaction include: Spontaneous colonic perforation, promotion of autonomic dysreflexia, and other life-threatening complications Damaged colonic mucosal during disimpaction, which can cause hemorrhoids and/or bacterial sepsis [calder.med.miami.edu]

  If left untreated, undiagnosed fecal impactions can lead to infection, and in some of the worst cases blood poisoning or sepsis. [mcgowanhood.com]

  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. [symptoma.com]

• Inflammation

  There are some data suggesting that FC levels may vary according to disease location, with it being less reliable in small bowel inflammation ( 7 ). [frontiersin.org]

  Read Now The Mesentery, Systemic Inflammation, and Crohn’s Disease Edgardo D Rivera, MD; John Calvin Coffey, PhD; Dara Walsh; et al. [journals.lww.com]

  […] affecting certain parts of the child’s body, such as the back, legs, shoulders, or neck Dizziness, fatigue, vomiting, or a loss of appetite Feeling so irritated that they find it hard to sleep or lack quality sleep Frequent urination alongside bladder inflammation [samitivejhospitals.com]

  Stool pressing on the intestinal wall also causes inflammation that may cause liquid secretion by intestinal wall tissue. This looks like watery diarrhea. [buoyhealth.com]

  Celiac disease is characterized by small bowel mucosal inflammation from intolerance to dietary gluten and is most common in whites of northern European ancestry. [aafp.org]

• Constipation

  Constipation and fecal impaction are common problems in the elderly institutionalized patient. In this day of increasing life expectancy and polypharmacy we can anticipate that we shall continue to encounter this problem. [journals.lww.com]

  It is most often seen in people who are constipated for a long time. Constipation is when you are not passing stool as often or as easily as is normal for you. Your stool becomes hard and dry. This makes it difficult to pass. [nlm.nih.gov]

  Abstract 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]

  METHODS: Children (4–16 years) with functional constipation and RFI participated. One week before disimpaction, a rectal examination was performed, symptoms of constipation were recorded, and the first CTT measurement was started. [pediatrics.aappublications.org]

• Diarrhea

  Fecal impaction was the most common cause of diarrhea (in 55%). Diarrhea was induced by laxatives in 20%. Gastrointestinal infections caused 5% of the diarrhea cases. [ncbi.nlm.nih.gov]

  The first indication of the impaction may be diarrhea and rectal incontinence that the unsuspecting physician may treat with an antidiarrheal agent, thereby compounding the problem. [journals.lww.com]

  Complications may include: Tear (ulceration) of the rectal tissue Tissue death ( necrosis ) or rectal tissue injury Tell your provider if you have chronic diarrhea or fecal incontinence after a long period of constipation. [nlm.nih.gov]

  As strange as it seems a hamster with a fecal impaction may also experience explosive diarrhea as liquid stools are able to past around the impaction it can cause diarrhea or uncontrolled leakage of loose stools, the diarrhea will not clear the impaction [hammysworld.com]

  Fecal impaction with overflow diarrhea. E. Irritable bowel syndrome. Discussion The answer is D: fecal impaction with overflow diarrhea. Fecal impaction is common and can affect individuals of any age. [aafp.org]

• Abdominal Pain

  Symptoms of fecal impaction extend from constipation, anorexia, nausea, vomiting and abdominal pain, to full blown sepsis. [ncbi.nlm.nih.gov]

  Successful rectal disimpaction, defecation and fecal incontinence frequencies, occurrence of abdominal pain and watery stools, CTTs (before and after disimpaction), and behavior scores were assessed. [pediatrics.aappublications.org]

  Abdominal pain was evaluated in the applied questionnaire, according to the modified Wong-Baker facial scale of pain, and scored as follows: 0 = no pain, 2 = mild pain, 4-6 = moderate pain, and 8-10 = severe pain.3 The statistical analyses were evaluated [revistagastroenterologiamexico.org]

• Vomiting

  Symptoms of fecal impaction extend from constipation, anorexia, nausea, vomiting and abdominal pain, to full blown sepsis. [ncbi.nlm.nih.gov]

  Clinical History 66 Y.O. female with abdominal pain and vomiting for 15 days. Known case CRF. Palpable mass on PR. Imaging Findings 66 Y.O. female presented with abdominal pain and vomiting for 15 days. There is palpable mass on PR. [eurorad.org]

  Nasogastric suction to decompress the upper GI tract may be necessary in chronic SCI and fecal impaction, where the distal colon may be damaged from distention and chemical damage, and there is vomiting, abnormal bowel sounds, severe dehydration, and [calder.med.miami.edu]

  Sign In A 49-year-old man with a history of paraplegia due to poliomyelitis, surgical treatment of a lumbar ependymoma, and chronic renal insufficiency due to a neuropathic bladder was admitted to the intensive care unit because of abdominal pain, vomiting [nejm.org]

• Nausea

  Symptoms of fecal impaction extend from constipation, anorexia, nausea, vomiting and abdominal pain, to full blown sepsis. [ncbi.nlm.nih.gov]

  GASTROINTESTINAL DYSFUNCTION: COLON AND ANORECTUM: FECAL IMPACTION Fecal Impaction Signs, symptoms, incidence, and diagnosis of fecal impaction in SCI include: Loss of appetite and nausea, common upon admission to rehab facility Abdominal distension and [calder.med.miami.edu]

  […] motility (anticholinergics, antipsychotics, opioids) Anatomic abnormalities (malignancy, anorectal disease, Hirschsprung's disease) Neurologic conditions (dementia, spinal cord injury, cerebral palsy) Clinical Features History Abdominal pain or bloating Nausea [wikem.org]

  She described abdominal pain that had been progressing for one week with associated overflow diarrhea, nausea and vomiting. Lab work showed deterioration of renal function with a creatinine level of 3.23mg/dL. [elsevier.es]

• Ulcer

  The complications of a fecal impaction are, fortunately, not common but include urinary tract obstruction, perforation of the colon, dehydration, electrolyte imbalance, renal insufficiency, fecal incontinence, decubitus ulcers, stercoral ulcers, and rectal [journals.lww.com]

  Clinical manifestations include fecal incontinence, abdominal distention and pain, anorexia, weight loss, intestinal obstruction, and stercoral ulceration with bleeding or colonic perforation. [ncbi.nlm.nih.gov]

  CONCLUSION: A timely surgical intervention in recalcitrant fecal impactions may prevent possible stercoral ulcer perforation with a high mortality. [dx.doi.org]

• Prolapse

  It causes severe pain, sometimes with bleeding, particularly with defecation... read more, and rectal prolapse Rectal Prolapse and Procidentia Rectal prolapse is painless protrusion of the rectum through the anus. [msdmanuals.com]

  Intestine that protrudes from the anus (rectal prolapse). Straining to have a bowel movement can cause a small amount of the rectum to stretch and protrude from the anus. Prevention The following can help you avoid developing chronic constipation. [mayoclinic.org]

  Pelvic floor dyssynergia Encopresis Commonly Associated Conditions Pulmonary aspiration Urinary tract obstruction Recurrent UTIs Intestinal obstruction Spontaneous perforation of colon Stercoral ulceration Hernia Volvulus Megacolon or megarectum Rectal prolapse [tipsdiscover.com]

  Rectal prolapse, in which a small amount of intestinal lining pushes out from the anal opening. [choc.org]

  […] extraluminal obstruction from adhesion, and anastomotic stricture can also cause fecal impaction.4,10 In addition to these etiologic factors, anatomic and functional abnormalities of the anorectum should be considered and excluded such as pelvic floor prolapse [ncbi.nlm.nih.gov]

• Fear

  Fearing deportation, many victims remain silent instead ofcollaborating with law enforcement officials to prosecute criminals. [phr.org]

  Children may get a fecal impaction when they withhold stool during toilet training, develop a fear of passing stool due to previous pain or discomfort, avoid using the bathroom because they don't want to interrupt their play, or don't drink enough fluids [everydayhealth.com]

  Stool avoidance behavior occurs when children experience painful bowel movements or fear having a bowel movement. [rileychildrens.org]

  The data confirm that fear, meaning plastic fibers are moving up the food chain. I grew up in those waters, and it hits very close to home to think of how contaminated they are. We must change our consumer habits to end plastic pollution.” [plasticoceans.org]

  She feared it would damage her daughter's career. Now she thinks differently. "He's lied a lot in his life," she said. "I know exactly what he is." [bbc.co.uk]

• Anger

  It’s a pouring out of anger but if you have anger without analysis, it can’t go far. It needs to go beyond denunciation.” [csmonitor.com]

  Effect on Individual: Feeling of insecurity, anger, apathy, dependence, guilt, indignity, feeling of abandonment, shame, embarrassment, depression and denial are common. Women feel loss of self-confidence and self-esteem. [womenshealthsection.com]

• Hunger

  […] active Medical problems that make it hard to pass stools Symptoms Symptoms may include: Straining, with problems passing stools Belly pain or rectal discomfort Belly swelling Nausea and vomiting Leaking stool or sudden episodes of watery stool Lack of hunger [winchesterhospital.org]

  These are three factors often involved in elderly patients in nursing homes and similar facilities; the combination of age-related degradation of colon function, lower thirst and hunger, and lack of physical activity create ideal conditions for constipation [gastrosav.com]

• Dizziness

  Call 911 immediately if you have trouble breathing, a fast or irregular heartbeat, or are dizzy or confused. Diagnosis There are several ways that your doctor can find out if you have a fecal impaction. Medical history. [webmd.com]

  These include: back pain due to the mass of poo pressing on the nerves in your lower back (the sacral nerves) a swollen tummy (abdomen) high or low blood pressure a fast heart rate dizziness sweating a high temperature (fever) severe diarrhoea that you [cancerresearchuk.org]

  Fever, chills, lightheadedness/dizziness, or sudden extreme worsening of abdominal pain. (These symptoms might happen if the mass pokes a hole in your intestinal wall.) [buoyhealth.com]

  […] these occur: Fever of 100.4°F (38°C) or higher, or as directed by your healthcare provider You still don't have normal bowel movements Abdominal or back pain gets worse Vomiting Abdominal swelling Blood in the stool, or black, tarry school Weakness, dizziness [mountnittany.org]

  However, in addition to those symptoms the individual may have bladder problems, back pain, nausea, vomiting, dehydration, a distended abdomen, a rapid heartbeat, sweating, fever, dizziness and even high or low blood pressure. [streetdirectory.com]

• Stroke

  The likelihood of fecal impaction increases with age, spinal injury, and neuropsychiatric disorders, so most cases are seen in patients with dementia, Alzheimer’s disease, Parkinson’s disease, stroke, spina bifida, and paralysis. [piemed.com]

  Lack of mobility because of aging, stroke or spinal cord injury may also lead to faecal impaction. This is due to colonic mass movement retardation and muscle weakness in the abdominal and the pelvis. [imagejournals.org]

  Causes include: Damage to the nerves that control bodily functions (autonomic neuropathy) Multiple sclerosis Parkinson's disease Spinal cord injury Stroke Difficulty with the muscles involved in elimination Problems with the pelvic muscles involved in [mayoclinic.org]

  […] factor for constipation due to decreasing bowel motility and a blunted motor response to eating.2 Additionally, a number of other etiologies and contributing factors to constipation exist, including low fiber intake, dehydration, spinal cord injury, stroke [westjem.com]

• Dyspareunia

  In the presence of stress incontinence and dyspareunia bio-psychosocial morbidity could be severe. Pelvic dysfunction can contribute to relationship problems with their infant or with their partner. [womenshealthsection.com]

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.

• Hyponatremia

  LABORATORY FINDINGS include: 1• Leukocytosis to 15,000 WBC/cu.mm 2• Hyponatremia 3• Hypokalemia 4• Stool may be positive for occult blood 5• Anemia, due to blood loss. [eurorad.org]

  Loss of sphincter tone: Neurologic disorders Large mass of stool palpable in lower left quadrant and rectal vault Diagnostic Tests & Interpretation Lab Often normal Leukocytosis to 15,000 WBCs/mm 3 Hyponatremia Hypokalemia Hypercalcemia TSH Stool may [tipsdiscover.com]

• Colitis

  Stercoral colitis: diagnostic value of CT findings. Diagn Interv Radiol. 2017;23(1):5-9. [wikem.org]

  Register now Become a Foundation Member By becoming a Professional Member of the Crohn's & Colitis Foundation, you will establish yourself as a leader and specialist in Crohn's disease and ulcerative colitis. [journals.lww.com]

  Crohn's Disease (CD), and (3) the T72 infliximab trial in pediatric Ulcerative Colitis (UC). [insights.ovid.com]

  Cases with demonstrated colitis on the tissue sample or wall thickening by abdominal ultrasound, without evidence of ulcer or perforation, were classified as “colitis”. [bmcgeriatr.biomedcentral.com]

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.

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.

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.

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].

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.

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.

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.

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.

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.