Refractory Ileal Fecaloma Causing Small Bowel Obstruction

Abstract

Fecalomas are extremely rare and often occur in the in the rectum and sigmoid colon. In patients with multiple comorbidities limiting clinical decisions, it is important to understand the treatment options available with fecalomas and their outcomes. Here we present a 61-year-old ventilator-dependent male with advanced dementia, status post heart and lung transplant, and status post prior small bowel resection for unclear reasons who presented with abdominal distention and bilious emesis following a recent hospitalization for respiratory failure secondary to pneumonia. Vitals were notable for tachycardia to the 110s and exam was significant for palpable stool along the right side of abdomen. An abdominal radiograph revealed dilated loops of small and large bowel with air-fluid levels (Figure 1). Conservative treatment with a nasogastric tube, crystalloids, and rectal laxatives were unsuccessful. An abdominal CT scan showed a dilated fluid-filled small bowel extending to distal ileum where there was a 9 cm stool ball in a postsurgical aperistaltic segment of bowel with distinct transition point (Figure 2). Multiple attempts at laxatives from patient's gastrostomy tube and rectally were trialed with no significant improvement in patient's abdominal distension and pain. Unfortunately, the patient was a poor candidate for surgery due to his multiple comorbidities. The family ultimately decided to pursue hospice. Fecalomas, or hard intraluminal tumor-like mass of feces, are most commonly found in the rectum and sigmoid colon. It has been more commonly reported in patients with old age, long-term enteral feeding, and neuropsychiatric disease, likely leading to sluggish bowel function. Fecalomas in the small bowel causing obstruction has only been reported in a 10-year-old boy. Fecalomas in the distal colon are often managed by conservative methods such as bowel rest, rectal suppositories, enemas, digital evacuation and rectal decompression. More aggressive treatments include endoscopic disimpaction and surgical intervention for those who are otherwise good surgical candidates. Our case posed a management dilemma in that the fecaloma was located in an aperistaltic segment of the ileum rather than more distally, making colonoscopic decompression difficult, and as patient was not a surgical candidate, surgery was a nonviable option. Since patient has exhausted all conservative managements, comfort care became the best available option.Figure: An abdominal radiograph showing dilated loops of small and large bowel obstruction with air-fluid levels.Figure: An abdominal CT scan showing a 9 cm stool ball in a postsurgical aperistaltic segment of bowel with a distinct transition point.