3059 A Serious Case of Fecal Impaction

Abstract

INTRODUCTION: Fecal impaction is well described in the elderly and those with neurologic or psychiatric diseases, immobility, structural colon or anorectal abnormalities. Despite numerous laxatives on the market, chronic constipation remains a major problem. This case highlights fecal impaction, whether associated with underlying comorbidities or not, can lead to serious complications. CASE DESCRIPTION/METHODS: A 20 year old male presented with bilateral leg weakness and ataxic gait. CT scan showed massive stool burden in the rectum, distended to 11.3 cm by 10.4 cm. There was a resulting mass effect on the bladder and lumbar nerve roots. He underwent fecal disimpaction in the operating room under general anesthesia. Manual evacuation was performed followed by insertion of 32F chest tube and irrigation with normal saline, mineral oil and milk of magnesia. Post-op day 2, the patient was able to ambulate normally and was discharged. DISCUSSION: Causes of fecal impaction include colon cancer, strictures, adhesions, rectoceles as well as Hirschsprung's and Chagas disease. Manual disimpaction and enemas should first be attempted. If no success, rectal tube placement past the point of obstruction and irrigation, as in our case, is reasonable. Sigmoidoscopy is another option. Washout using oral laxatives can be attempted but is contraindicated with concurrent bowel obstruction. In extreme cases, decompressive laparotomy may be necessary. While any of these treatments can be attempted, prevention is key. Adequate fiber and hydration and biofeedback for anorectal dysfunction are crucial. Discontinuation of medications including opiates and anticholinergics are also important. If left untreated, complications include stercoral ulcer leading to hemorrhage, hydronephrosis, SIRS, bacteremia, perforation and even death. In a systematic review by Falcon et al., the most common complication was perforation, followed by obstruction, ulcer, and finally obstructive uropathy. Our case report is unique in identifying a young patient with such severe fecal impaction that led to neurologic compromise. Unfortunately, he never presented for outpatient followup and therefore no colonoscopy or anorectal manometry was done. Our patient could potentially have developed permanent neurologic sequelae, perforation and even death if treatment was delayed any further. This case highlights fecal impaction, whether associated with underlying comorbidities or not, can lead to serious complications therefore mandating prompt diagnosis and treatment.