Fecal Disimpaction Research Articles

Evaluation and Management of Pediatric Constipation

Constipation is one of the most common problems evaluated by pediatricians, pediatric gastroenterologist, and pediatric surgeons alike. A clear and concise management algorithm is needed to appropriately treat patients and avoid unnecessary outpatient and emergency department visits. Once organic causes of constipation have been ruled out, treatment should progress in a stepwise fashion until success, defined as daily bowel movements without encopresis or overflow pseudoincontinence. Therapy should begin with diet modification and progress through the use of polyethylene glycol, stimulant laxatives, daily enemas, and even formal inpatient fecal disimpaction. For those patients who fail to successfully evacuate their colons or those who have persistent incontinence secondary to severe constipation, surgical options such as appendicostomy should be explored. Ultimately, we must all accept that constipation can be a severe, life-altering problem which should be addressed with an aggressive management strategy.

Pediatrician's knowledge on the approach of functional constipation

ObjectiveTo evaluate the pediatrician's knowledge regarding the diagnostic and therapeutic approach of childhood functional constipation. MethodsA descriptive cross-sectional study was performed with the application of a self-administered questionnaire concerning a hypothetical clinical case of childhood functional constipation with fecal incontinence to physicians (n=297) randomly interviewed at the 36th Brazilian Congress of Pediatrics in 2013. ResultsThe majority of the participants were females, the mean age was 44.1 years, the mean time of professional practice was 18.8 years; 56.9% were Board Certified by the Brazilian Society of Pediatrics. Additional tests were ordered by 40.4%; including abdominal radiography (19.5%), barium enema (10.4%), laboratory tests (9.8%), abdominal ultrasound (6.7%), colonoscopy (2.4%), manometry and rectal biopsy (both 1.7%). The most common interventions included lactulose (26.6%), mineral oil (17.5%), polyethylene glycol (14.5%), fiber supplement (9.1%) and milk of magnesia (5.4%). Nutritional guidance (84.8%), fecal disimpaction (17.2%) and toilet training (19.5%) were also indicated. ConclusionsOur results show that pediatricians do not adhere to current recommendations for the management of childhood functional constipation, as unnecessary tests were ordered and the first-line treatment was not prescribed.

Pharmacological interventions on early functional gastrointestinal disorders.

BackgroundFunctional gastrointestinal disorders (FGIDs) are chronic or recurrent gastrointestinal symptoms without structural or biochemical abnormalities. FGIDs are multifactorial conditions with different pathophysiologic mechanisms including altered motility, visceral hyperalgesia, brain-gut disturbance, genetic, environmental and psychological factors.Although in most cases gastrointestinal symptoms are transient and with spontaneous resolution in infancy multiple dietary changes and pharmacological therapy are often started despite a lack of evidence-based data. Our aim was to update and critically review the current literature to assess the effects and the clinical appropriateness of drug treatment in early (occurring in infants and toddlers) FGIDs.MethodsWe systematically searched the Medline and GIMBE (Italian Group on Medicine Based on Evidence) databases, according to the methodology of the Critically Appraised Topics (CATs). We included reviews, clinical studies, and evidence-based guidelines reporting on pharmacological treatments. Systematic reviews and randomized controlled trials (RCTs) concerning pharmacologic therapies in children with early FGIDs were included, and data were extracted on participants, interventions, and outcomes.ResultsWe found no evidence-based guidelines or systematic reviews about the utility of pharmacological therapy in functional regurgitation, infant colic and functional diarrhea. In case of regurgitation associated with marked distress, some evidences support a short trial with alginate when other non pharmacological approach failed (stepped-care approach). In constipated infants younger than 6 months of age Lactulose is recommended, whilst in older ages Polyethylene glycol (PEG) represents the first-line therapy both for fecal disimpaction and maintenance therapy of constipation. Conversely, no evidence supports the use of laxatives for dyschezia. Furthermore, we found no RCTs regarding the pharmacological treatment of cyclic vomiting syndrome, but retrospective studies showed a high percentage of clinical response using cyproheptadine, propanolol and pizotifen.ConclusionThere is some evidence that a pharmacological intervention is necessary for rectal disimpaction in childhood constipation and that PEG is the first line therapy. In contrast, for the other early FGIDs there is a lack of well-designed high-quality RCTs and no evidence on the use of pharmacological therapy was found.

Conhecimento do pediatra sobre o manejo da constipação intestinal funcional

ObjectiveTo evaluate the pediatrician's knowledge regarding the diagnostic and therapeutic approach of childhood functional constipation. MethodsA descriptive cross‐sectional study was performed with the application of a self‐administered questionnaire concerning a hypothetical clinical case of childhood functional constipation with fecal incontinence to physicians (n=297) randomly interviewed at the 36th Brazilian Congress of Pediatrics in 2013. ResultsThe majority of the participants were females, the mean age was 44.1 years, the mean time of professional practice was 18.8 years; 56.9% were Board Certified by the Brazilian Society of Pediatrics. Additional tests were ordered by 40.4%; including abdominal radiography (19.5%), barium enema (10.4%), laboratory tests (9.8%), abdominal ultrasound (6.7%), colonoscopy (2.4%), manometry and rectal biopsy (both 1.7%). The most common interventions included lactulose (26.6%), mineral oil (17.5%), polyethylene glycol (14.5%), fiber supplement (9.1%) and milk of magnesia (5.4%). Nutritional guidance (84.8%), fecal disimpaction (17.2%) and toilet training (19.5%) were also indicated. ConclusionsOur results show that pediatricians do not adhere to current recommendations for the management of childhood functional constipation, as unnecessary tests were ordered and the first‐line treatment was not prescribed.

Traitements de la constipation du nourrisson et de l’enfant

Functional constipation is a common pediatric problem in general practice and even more so in pediatric gastroenterology clinics. Treatment is often delayed with psychosocial and digestive consequences. However, treatment is well codified and effective. Hyperosmotic mineral water, diet, and endoanal medications are not treatments for established constipation, whatever the age. The lactulose/lactitol-based medications are authorized and effective before 6 months of age and polyethylene-glycol for infants over 6 months. Mineral oil is less prescribed. The rule for treatment is a sufficient dose for a long time. In case of fecal impaction with or without fecal incontinence, the first stage is fecal disimpaction, using a high dose of PEG the first few days, or repeated phosphate enemas. Education regarding the adaptation of toilets and a daily bowel movement should restore colic motility and avoid relapses when the treatment is discontinued. Psychological concerns should be evaluated and treated.

OP‐10 EFFICACY AND SAFETY OF ENEMAS ADMINISTERED HIGH IN THE RECTUM FOR FECAL DISIMPACTION IN CHILDREN.

Aim:Efficacy and safety of enemas administered high in the rectum for fecal disimpaction in children was evaluated by a retrospective cohort study.Methods:Between January 1, 2012 and January 1, 2014 all procedures were evaluated. All enemas were administered, using a standardized in‐house protocol, so all procedures were performed in the same way. An enema high in the rectum was considered effective, if stool production exceeded the amount of stools that is regarded normal for the age and weight of the patient, and if the patient felt relieved after the production of stools.A qualitative scale was used by the nursing staff to estimate the amount of stools produced by the patient (‘none’, ‘little’, ‘normal’, ‘many’). Stool consistency was scored, using Bristol Stool Scale. Total stool production within 12 hours after enema was scored. Literature review was performed on efficacy and safety of enemas high in the rectum.Results:N = 77 procedures were evaluated in which all data were documented. Enemas were administered in N = 75 children (36 girls/39 boys: mean age: 9.8 yr (3.6 ‐ 19)(range)). Fecal impaction was present, defined as: palpable mass in abdomen or in rectum and a history of low stool frequency. N = 25 children were treated with more than one enema during the studied period. 68 % of enemas were effective for acute disimpaction. In 30 (45%) procedures, many stools were evacuated, in 15 (23%) procedures the amount was normal; in 18 (27%) procedures there was little stool production and in 3 (5%) procedures no stools were produced. In N = 11 procedures the amount of stools produced was documented insufficiently. Procedure‐ related complications were not seen. In literature no data were found on the efficacy or on safety of enemas administered high up in the rectum. Literature shows equal efficacy of high dose (oral) macrogol as compared to standard rectal enemas (not high up).Conclusions:Enemas administered high up in the rectum are safe in all, and effective in a majority of patients for the management of fecal impaction in children. Prospective studies are needed to evaluate efficacy of enemas high up in the rectum as compared to high doses of macrogol for fecal disimpaction in children.

Disimpaction of children with severe constipation in 3–4 days in a suburban clinic using polyethylene glycol with electrolytes and sodium picosulphate

Constipation is a common cause of admission to hospital for disimpaction, as oral laxatives are often inadequate. High-dose oral laxative protocols are used for complete bowel clearance prior to colonoscopy, but have not been reported for treating faecal impaction. The aim of this study was to assess the effectiveness of a high-dose oral protocol using polyethylene glycol with electrolytes (PEG + E) (Movicol Rx) combined with sodium picosulphate (SP) (Dulcolax SP Rx) in faecal impaction in children presenting to a suburban clinic. Forty-four children presented with acute/chronic faecal impaction were given six to eight sachets of PEG + E were given on day 1, with decreasing doses on subsequent 3 days, while 15-20 SP drops were given on days 2 and 3. Compliance with medication was achieved using a simple method of motivation, with the child drinking the laxatives in a race. On day 4, PEG + E was reduced to one sachet and SP to 10 drops as an ongoing maintenance dose. Defecation, soiling, diet and water intake was monitored daily for 7 days in a diary. Forty-four children (aged 2-17 years) seen over 8 months were reviewed retrospectively. Children began defecating within 10-12 h reaching a maximum volume of stool/day (four cups) on day 2. All patients were disimpacted successfully and in the week following disimpaction there was no reported faecal soiling or complications. A high-dose oral protocol combining PEG + E sachets and SP drops successfully and safely disimpacted a cohort of children with acute/chronic constipation presenting to a suburban continence clinic. This protocol appears to be useful to control faecal disimpaction in an outpatient setting, thereby avoiding hospital admission.

Potentially avoidable hospitalisation for constipation in Victoria, Australia in 2010-11.

BackgroundWhen primary care of constipation fails, the patient may need emergency hospitalisation for disimpaction. This study aimed to provide population-based data on the number of unplanned admissions and the cost to the healthcare system for constipation in Victoria, Australia in financial year 2010–11.MethodsThe Victorian Admitted Episodes Dataset was examined to find the number of emergency hospital separations coded as constipation (ICD-10-AM Code K390). An estimate of costs was determined from the number of weighted inlier equivalent separations (WIES) multiplied by the WEIS price, used by the Victorian Government for funding purposes.ResultsThere were 3978 emergency separations for constipation in Victoria in 2010–2011, 92% in public hospitals. Fifty-five percent were female and 38% > 75 years old. One third stayed overnight and 1/3 more than 1 day. The emergency bed day rate was 7.1 per 10,000 of population. The estimate of cost, based on WEIS, was approximately $8.3 million. Potential savings could be made by reducing the number of separations in 6 Local Government Areas (LGAs).ConclusionsThis study shows that the burden (in number of admissions, emergency bed days and overall direct costs) in managing emergency admissions for constipation in Victoria, Australia, is very significant and likely to be similar in other developed countries. Improved primary healthcare and alternative ways to achieve faecal disimpaction without emergency admission could save the public health system a proportion of this $8.3 million.

Colonic duplication with recto-urethral fistula: Elusive diagnosis and successful treatment in a resource-limited setting

A 3-year-old Ugandan boy presented with 18 months of constipation and 12 months of pneumaturia and fecaluria. Physical exam revealed abdominal distension and a palpable mass anterior to the rectum. Previous contrast enema had been non-diagnostic, and a voiding cystourethrogram (VCUG) had confirmed a recto-urethral fistula. After surgical evaluation, a computed tomography (CT) scan suggested colonic duplication, and a laparotomy was performed for rapidly progressive bowel obstruction. A tubular colonic duplication with fecal impaction was found, necessitating fecal disimpaction and a double divided colostomy. Two months later at re-laparotomy, the septum between the duplicated colonic lumens was found to extend proximally to the mid transverse colon and distally to the upper rectum, and was divided. No urethral fistula was identified, and the colostomy was recreated. At a third operation, the colostomy was reversed. The patient is well at one-year follow up, without evidence of recurrent fistula or stricture. This case shows that colonic duplication in children can be an elusive diagnosis. Often, a variety of radiographic studies may be needed and may be difficult to interpret. In cases with colo-urinary fistula, the fistula may respond to fecal diversion without requiring operative repair. Management in a resource-limited setting can still yield positive outcome. • Colonic duplication in children can be an elusive diagnosis. • A variety of radiographic studies may be needed and may be difficult to interpret. • Colo-urinary fistula may respond to fecal diversion without requiring operative repair. • Management in a resource-limited setting can still yield positive outcome.

An Occurrence of Sepsis During Inpatient Fecal Disimpaction

Functional constipation is a common pediatric problem that is often treated through well-established algorithms. Fecal disimpaction is the initial therapeutic step, and severe cases require hospitalization for intensive therapies. We describe a significant unexpected complication of this common clinical situation. An 8-year-old boy with suspected chronic functional constipation was hospitalized for disimpaction by continuous nasogastric administration of polyethylene glycol electrolyte (PEG-E) solution. On the sixth day of disimpaction, the patient abruptly developed fever, tachycardia, and tachypnea. Evaluation included blood culture, which grew Escherichia coli, and treatment with a course of appropriate antibiotics was provided. The safety of PEG-E solutions has been shown in studies of children with constipation, which made this patient's illness surprising. Several potential etiologies of his infection were considered, including bacterial translocation (BT). BT is defined as the passage of live microbes and microbial products from the gastrointestinal tract to extraintestinal sites, such as the bloodstream. It has been shown to occur in a variety of clinical conditions but is of unclear clinical significance. In this case, physical damage to the intestinal mucosa was thought to contribute to the potential occurrence of BT, and prolonged disimpaction was considered as a risk factor. E coli sepsis in a child undergoing inpatient nasogastric fecal disimpaction with PEG-E represents a clinical problem never before reported in the literature and should increase clinicians' indices of suspicion for uncommon complications of common procedures.

An Unusual Presentation of Fecal Impaction

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

Abdominal radiograph in the assessment of fecal impaction in children with functional constipation: comparing three scoring systems

To compare three radiological scores in the study of fecal impaction in children with constipation. To investigate whether these radiological scores are useful in the assessment of fecal disimpaction therapy and if they present a relation with total colonic transit time. The Barr, Blethyn and Leech scores were measured by three observers, independently, in 123 abdominal radiographs. Interobserver agreement in the diagnosis of fecal impaction was calculated for the three scores. In 30 radiographs, the analysis of the scores was performed before and after fecal disimpaction. Total colonic transit time was calculated in 59 radiographs with the use of radiopaque markers. The agreement between pairs of observers was assessed by the kappa coefficient and was good for the Barr (0.56, 0.59 and 0.69) and Leech scores (0.53, 0.58 and 0.61). The Blethyn score presented lower kappa coefficients (0.26, 0.32 and 0.36). In the comparison of methods, Leech and Barr showed a good correlation. After fecal disimpaction, there was a statistically significant reduction (p < 0.001) of scores, most significantly with the Barr score. There was no relation between radiographic scores and colonic transit time. There is no relation between fecal impaction assessed by radiography of the abdomen and total colonic transit time. Plain radiographs may be a useful tool for the diagnosis of fecal impaction. The Barr score can be considered a good method of analysis, especially to assess the response to treatment of fecal impaction.

A Randomized Trial of Enema Versus Polyethylene Glycol 3350 for Fecal Disimpaction in Children Presenting to an Emergency Department

This study aimed to compare efficacy of enema versus polyethylene glycol (PEG) 3350 for pediatric fecal impaction treatment. We conducted a prospective, randomized comparison of treatments of fecal impaction in children in a pediatric emergency department (ED). Treatment arms were a single milk and molasses enema in the ED or PEG 3350 for 3 days outpatient. Telephone follow-up was done on days 1, 3, and 5. The primary outcome was main symptom improvement. Additional outcomes were stool frequency, consistency, and ease of stool passage. Treatment failures (home enema, ED return, or hospital admission) were tracked. Seventy-nine subjects participated (39 PEG; 40 enema). At day 1, PEG subjects were less likely to have improved main symptom (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.8) but no difference in other outcomes. Half (54%) in enema arm were reported as upset by ED therapy, whereas no children in PEG arm were upset (P < 0.05). At day 3, more patients in enema arm reported ideal stool consistency (74% vs 38%; P < 0.05). At day 5, no difference between groups was noted. Most treatment failures were in PEG arm (83%; P = 0.08). This pilot study suggests that disimpaction by enema may be superior to PEG for immediate relief of symptoms. Larger trials are needed to assess any advantage.

Managing functional constipation in children

Constipation is a common childhood problem, with both somatic and psychological effects. The etiology of paediatric constipation is likely multifactorial, and seldom due to organic pathology. Children benefit from prompt and thorough management of this disorder. The goal of treatment is to produce soft, painless stools and to prevent reaccumulation of feces. Education, behavioural modification, daily maintenance stool softeners and dietary modification are all important components of therapy. Fecal disimpaction may be necessary at the outset of treatment. Investigations are rarely necessary. Polyethylene glycol is a safe, effective and well-tolerated long-term treatment for constipation. Regular follow-up for children with constipation is important. Referral to a gastroenterologist should be made in refractory cases or when there is a suspicion of organic pathology.

Massive Portal Venous Gas Related to Small Bowel Ischemia

Purpose: Aim: To describe a case of massive portal venous gas (PVG) related to small bowel ischemia and highlight the radiographic findings related to this clinical entity. Case Report: A morbidly obese and diabetic 76 yo female presented with a 3 day history of constipation, mid abdominal pain and vomiting. Surgical history was significant for prior hysterectomy with partial colon resection, temporary colostomy placement and incidental appendectomy in the remote past (related to a migrated intrauterine device). Upon admission, CT of the abdomen/pelvis revealed dilated loops of small bowel and a ventral hernia which contained a loop of transverse colon. The latter had been seen on a CT scan performed 2 years previously. The primary care team believed symptoms were related to a fecal impaction, and the patient was treated with manual fecal disimpaction, tap water enemas and intravenous hydration. 72 hours following hospital admission, abdominal pain worsened and vomiting recurred. An obstruction series revealed dilated small intestine and stomach, and the radiologist interpreted it as also demonstrating either pneumobilia or portal venous gas (PVG). 12 hours later, GI consultation was sought after dark red-colored hematemesis occurred. At this point the patient became hypotensive and required vigorous intravascular fluid expansion and a vasopressor to maintain relative hypotension. Review of the recently performed plain abdominal radiograph suggested that massive PVG was undoubtedly present (branching air lucencies were noted to extend to the periphery of the liver). Intestinal ischemia was suspected, broad-spectrum antibiotics were started and immediate laparotomy was orchestrated (within 60 minutes of GI consultation). At laparotomy, the entire small bowel was severely ischemic-appearing, but it was macroscopically judged to be viable, after a pelvic adhesive band was lysed, which appeared to be the cause of intestinal obstruction and secondary ischemia (the ventral hernia which contained a loop of transverse colon was incidental). On the following day, hypotension persisted and both respiratory and renal failure ensued. Repeat laparotomy was declined by the patient and her family. The patient expired later that day. Conclusions: (1) Small intestinal obstruction should not be attributed to rectal fecal impaction, (2) PVG produces branching air lucencies which extend to the periphery of the liver, (3) In the setting of acute abdominal pain and hypotension, the finding of PVG suggests an intra-abdominal catastrophe which mandates emergent laparotomy.

Case 1: Going forward in lack of movement

A 12-year-old girl was referred to the paediatric gastroenterology service with a history of chronic constipation and fecal incontinence. The symptoms were present for seven years, with frequent passage of stools in the clothes. She also experienced intermittent nocturnal enuresis. There was no abdominal pain, bloating, nausea, vomiting, diarrhea, rectal bleeding, dysuria, chronic cough, fatigue or weight loss. Her history was otherwise unremarkable, with no problem passing meconium after birth and a normal stool pattern in infancy. Her growth and development were normal. The child was in foster care and a family history was not available. The patient was tried on a variety of laxative therapies including lactulose, oral polyethylene glycol and repeated rectal enemas. The patient had a difficult and protracted course over several years, with frequent stool incontinence. Cognitive behavioural therapy was provided by a professional psychologist. Due to uncertain compliance with oral therapy, lavage with polyethylene glycol via a nasogastric tube had been tried several times for fecal disimpaction. Investigations included normal thyroid function tests, serum calcium and urinalysis. An abdominal radiograph had revealed fecal loading in the distal colon. On examination, she was obese with a weight between the 90th and 95th percentiles, and a height between the 10th and 25th percentiles. Her body mass index was 29.8 kg/m2 (greater than the 97th percentile). There was no pallor, clubbing or thyromegaly. The abdomen was soft and nondistended, with no tenderness, organomegaly or masses. (A previous rectal examination conducted by the referring physician revealed stool in the rectum.) Examination of the nervous system and spine was normal. A diagnostic laboratory test was performed, which revealed the diagnosis.

Eosinophilic Myenteric Ganglionitis

Eosinophilic myenteric ganglionitis is a disorder characterized by infiltration of the Auerbach plexus by eosinophils. It can be associated with a bowel dysmotility and a few cases of intestinal pseudo-obstructive syndrome have been described in children. In this case report, we present an elderly 93-year-old woman who presented with episodes of functional bowel obstruction of unknown etiology. After several admissions for recurrent obstipation requiring fecal disimpaction, she had a Hartmann procedure performed with a resection of the sigmoid colon. The sigmoid colon was markedly dilated and the only significant finding on histology was infiltration of the Auerbach plexus by eosinophils. The mucosa and the muscular layers appeared unremarkable. Her symptoms resolved after the resection and the patient is currently well after 5 months. Recurrent gastrointestinal pseudo-obstruction can arise secondary to eosinophilic myenteric ganglionitis even in adults. Clinical improvement is likely if this disease entity is promptly recognized and treated.

Abdominal Compartment Syndrome Secondary to Chronic Constipation

Abdominal compartment syndrome (ACS) is defined as an elevated intraabdominal pressure with evidence of organ dysfunction. The majority of published reports of ACS are in neonates with abdominal wall defects and in adults following trauma or burns, but it is poorly described in children. We describe the unusual presentation of an 11-year-old boy with a long history of chronic constipation who developed acute ACS requiring resuscitative measures and emergent disimpaction. He presented with a 2-week history of increasing abdominal pain, nausea, diminished appetite and longstanding encopresis. On exam, he was emaciated with a massively distended abdomen with a palpable fecaloma. Abdominal XR confirmed these findings. Within 24 hours of presentation, he became tachycardic and oliguric with orthostatic hypotension. Following two enemas, he acutely deteriorated with severe hypotension, marked tachycardia, acute respiratory distress, and a declining mental status. Endotracheal intubation, fluid boluses, and vasopressors were commenced, followed by emergent surgical fecal disimpaction. This resulted in rapid improvement in vital signs. He has been thoroughly investigated and no other condition apart from functional constipation has been identified. Although ACS secondary to constipation is extremely unusual, this case illustrates the need to actively treat constipation and what can happen if it is not.

A Can of V8® Vegetable Juice Per Rectal Route

Purpose: Rectal foreign bodies can be a difficult diagnostic dilemma especially due to the reluctance with which patients disclose history pertaining to them. Presentation is usually delayed because of the perceived stigma associated with rectal problems. A 78-year old gentleman presented with a three-day history of vomiting, abdominal bloating and fecal incontinence symptoms. The vomiting occurred with every meal and consisted of undigested food. He had history of two weeks of chronic diarrhea but stool studies had been negative. Abdominal exam was significant for generalized tenderness and distension, without rebound or peritoneal signs. Digital rectal examination revealed a rock-hard but smooth surfaced mass deep in the rectal vault. A computed tomography scan revealed a distended rectum with “massive amounts of fecal material” and a “cylindrical object in the rectal pouch with an air-fluid level within the object”. Fecal disimpaction with digital manipulation was unsuccessful. The patient was re-interviewed but denied inserting any foreign body through his anus. Patient was taken to the operating theatre where the object was extracted under general anesthesia and found to be a 12 oz Can of V8® vegetable juice. The patient did not suffer any complications of perforation and his gastrointestinal symptoms resolved within the next 48 hrs. He was offered psychological support post-op which he accepted. This case serves to illustrate that very few people with anorectal foreign bodies will freely admit to trans-anal introduction.(1) In the referenced case, a digital rectal examination and radiological evaluation proved invaluable in clinching the diagnosis. As with our patient, offering psychological support without passing judgment is an important part of the post-extraction management.(2)Figure. V8: ® vegetable can in rectum.

Distal Intestinal Obstruction Syndrome (DIOS) in Patients with Cystic Fibrosis After Lung Transplantation

BackgroundCystic fibrosis (CF) is the commonest inherited life-threatening disease in Caucasians. With increased longevity, more patients with CF are developing gastrointestinal complications including the distal intestinal obstruction syndrome (DIOS), in which ileocecal obstruction is caused by viscid mucofeculent material. The optimal management of DIOS is uncertain. MethodsThe medical records of all patients with CF who underwent lung transplantation at this institution during a 15-year period were reviewed. The definition of DIOS required the presence of both clinical and radiological features of ileocecal obstruction. ResultsOne hundred twenty-one patients with CF underwent lung transplantation during the study period. During a minimum 2-year follow-up, there were 17 episodes of DIOS in 13 (10.7%) patients. The development of DIOS was significantly associated with a past history of meconium ileus (odds ratio 20.7, 95% C.I. 5.09–83.9) or previous laparotomy (odds ratio 4.93, 95% C.I. 1.47–16.6). All six patients who developed DIOS during the transplantation admission had meconium ileus during infancy, and five had undergone pretransplant laparotomy for CF complications. First-line treatment for all patients was a combination of medication (laxatives, stool softeners, and bowel preparation formulas). This was successful in 14 of the 17 DIOS but needed to be given for up to 14 days. The other three patients required laparotomy with enterotomy and fecal disimpaction. This provided definitive resolution of DIOS except in one patient who presented late and died despite ileal decompression and ileostomy. ConclusionsDIOS occurred in approximately 10% of CF patients after lung transplantation. Patients with a history of meconium ileus or previous laparotomy are at high risk of developing DIOS. Patients with DIOS require early aggressive management with timely laparotomy with enterotomy and possible stoma formation when non-operative therapy is unsuccessful.