An Unusual Presentation of Fecal Impaction

Abstract

Purpose: A 20-year-old man presented to an outside hospital for evaluation of acute onset of diffuse abdominal pain, distention and obstipation. The patient endorsed decreased urinary output in the past 48 hours prior to admission. The patient's history is significant for imperforated anus at birth status-post transperineal anorectoplasty at age 2 and renal agenesis with solitary left kidney. He reported previous episodes of constipation that had been managed with laxatives on an as needed basis. Computed tomography (CT) of the abdomen and pelvis revealed a massive stool-filled rectosigmoid colon complicated by hydronephrosis (Figure A, arrows). The patient was transferred to our institution for further management. Initial laboratories were remarkable for leukocytosis (WBC of 19,700 cells/mcL) and elevated serum creatinine (1.34 mg/dL). His abdominal distention and pain improved with passage of flatus and stool with vigorous use of laxatives and enemas. The patient's urinary output improved and serum creatinine returned to baseline (1.04 mg/dL) with fecal disimpaction and adequate hydration on the 4th day of hospitalization. Colonoscopy revealed a grossly dilated, redundant recto-sigmoid colon with congested erythematous mucosa. Prior to discharge, he was counseled on the importance of regular bowel medical therapy and scheduled for further evaluation and follow up with colorectal surgery as an outpatient. The occurrence of long-standing constipation, recurrent fecal impaction following surgical repair of imperforated anus has been previously described. The “mega recto-sigmoid” is presumed to be due to rectal ectasia with deficient propulsive function in spite of a repaired patent anal canal. This ineffective peristalsis can lead to massive fecalomas occupying the entire pelvis and lower abdomen, leading to complications, including obstructive uropathy as described in this case. It is important to recognize that the majority of these patients become refractory to even the most diligent medical therapy and highlights the importance of close follow-up and surgical consultation to prevent both the acute and long-term sequelae.Figure: [1138] Figure A