Fecal Impaction Research Articles

Utilisation and Safety of Polyethylene Glycol 3350 With Electrolytes in Children Under 2 Years: A Retrospective Cohort.

ABSTRACTObjectives:In the UK, Movicol paediatric plain (polyethylene glycol 3350 with electrolytes [PEG 3350+E], Norgine, UK), is licensed for chronic constipation in children 2 –11 years of age and faecal impaction (FI) from 5 years. This study aimed to investigate usage and characterise the risk profile in children under 2 years of age using PEG 3350+E in the UK.Methods:Retrospective, single exposure cohort study, with patients identified from Clinical Practice Research Datalink (CPRD) GOLD. Patients first prescribed PEG 3350+E under 2 years of age for the treatment of constipation or FI, between September 2003 and July 2019, were included.Results:There were 13,235 patients with a constipation indication and 40 patients with FI. For the constipation cohort: median age of PEG 3350+E first prescription was 1.2 years [interquartile range (IQR) 0.9, 1.6] and 68.4% had one treatment episode (TE). The mean duration of exposure, in the first TE, was 88.9 days. The most common total daily dose was one sachet (6.9 g).In terms of incident events on treatment, 0.5% of patients had abdominal pain, 3.0% had diarrhoea (may be attributed to treatment) and 4.1% had vomiting. 2.0% had signs/symptoms which could (in extreme cases) be associated with electrolyte disturbance, however, none had abnormal electrolyte values.Discussion:The safety aspect of this study did not identify any signals of concern in the constipation cohort. The number of patients in the FI cohort were too small for robust conclusions. If information were available, then a safety study would ideally assess treatment intake per kilogram, including electrolyte intake, before reaching safety conclusions. Nevertheless, these data contribute to real-world evidence on the use of PEG 3350+E in this population.

An Unusual Case of Thiamine Deficiency in a Total Parenteral Nutrition-Dependent Child Secondary to Munchausen by Proxy

An Unusual Case of Thiamine Deficiency in a Total Parenteral Nutrition-Dependent Child Secondary to Munchausen by Proxy

Substance Use Disorders in the Surgical Patient

Large bodies of evidence link alcohol consumption and substance use disorders (SUDs) with motor vehicle collisions, as well as life-threatening intentional injury. According to the substance use and mental health estimates from the 2013 National Survey on Drug Use and Health, 24.6 million individuals age 12 or older were current illicit drug users in 2013, including 2.2 million adolescents age 12 to 17, and 60.1 million individuals age 12 or older were binge drinkers in the past month. Many people with SUDs become patients; therefore, the surgeon must be able to recognize and manage many of the related issues that can ensue. This review details the definition of SUDs, basic principles of toxicology, acute management of the patient with suspected substance use intoxication or withdrawal, managing life-threatening syndromes in patients with SUDs, overdose and withdrawal syndromes of opioids, stimulants, and depressants, surgical complications of SUDs, perioperative and postoperative considerations in patients with SUDs, and consultation and referral to a toxicologist and poison control center. Figures show first- and zero-order kinetics; pupillary examination, laboratory and radiographic findings in SUDs; polymorphic ventricular tachycardia; consciousness as an interplay between arousal and awareness, an algorithm for the management of seizures, sine, mechanism of cocaine’s cardiac toxicity and hemorrhagic stroke in a cocaine abuser, necrotizing soft tissue infection, digit necrosis associated with intra-arterial injection of cocaine, scars from skin popping, nonocclusive thrombus in the left internal jugular vein, needle fracture with soft tissue dislodgment, oral contrast-enhanced computed tomographic scan showing rounded foreign bodies in the stomach, and fecal impaction associated with heroin. Tables list criteria for substance use disorders according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), frequently misused drugs, causes of death in SUD, cardiac, neurologic, and metabolic signs and symptoms caused by commonly abused substances , anion and osmolar gap equations, life-threatening manifestations of cocaine toxicity, and alcohol-related disorders. This review contains 15 figures, 8 tables, and 85 references.

Substance Use Disorders in the Surgical Patient

Large bodies of evidence link alcohol consumption and substance use disorders (SUDs) with motor vehicle collisions, as well as life-threatening intentional injury. According to the substance use and mental health estimates from the 2013 National Survey on Drug Use and Health, 24.6 million individuals age 12 or older were current illicit drug users in 2013, including 2.2 million adolescents age 12 to 17, and 60.1 million individuals age 12 or older were binge drinkers in the past month. Many people with SUDs become patients; therefore, the surgeon must be able to recognize and manage many of the related issues that can ensue. This review details the definition of SUDs, basic principles of toxicology, acute management of the patient with suspected substance use intoxication or withdrawal, managing life-threatening syndromes in patients with SUDs, overdose and withdrawal syndromes of opioids, stimulants, and depressants, surgical complications of SUDs, perioperative and postoperative considerations in patients with SUDs, and consultation and referral to a toxicologist and poison control center. Figures show first- and zero-order kinetics; pupillary examination, laboratory and radiographic findings in SUDs; polymorphic ventricular tachycardia; consciousness as an interplay between arousal and awareness, an algorithm for the management of seizures, sine, mechanism of cocaine’s cardiac toxicity and hemorrhagic stroke in a cocaine abuser, necrotizing soft tissue infection, digit necrosis associated with intra-arterial injection of cocaine, scars from skin popping, nonocclusive thrombus in the left internal jugular vein, needle fracture with soft tissue dislodgment, oral contrast-enhanced computed tomographic scan showing rounded foreign bodies in the stomach, and fecal impaction associated with heroin. Tables list criteria for substance use disorders according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), frequently misused drugs, causes of death in SUD, cardiac, neurologic, and metabolic signs and symptoms caused by commonly abused substances , anion and osmolar gap equations, life-threatening manifestations of cocaine toxicity, and alcohol-related disorders. This review contains 15 figures, 8 tables, and 85 references.

Rare case of fecal impaction caused by a fecalith originating in a large colonic diverticulum: A case report

BACKGROUNDFecal impaction is defined as a large mass of compacted feces in the colon and has the potential to induce a serious medical condition in elderly individuals. Fecal impaction is generally preventable, and early recognition of the typical radiological findings is important for making an early diagnosis. The factors that lead to fecal impaction are usually similar to those causing constipation. Few cases with fecal impaction associated with a diverticulum have been reported.CASE SUMMARYWe present the case of a 62-year-old woman who suffered from abdominal pain and vomiting, had a medical history of repeated acute abdomen and was diagnosed with fecal impaction in the descending colon based on X-ray and computed tomography (CT) imaging. After examination by gastrografin-enhanced colonography following colonoscopy and CT colonography, the fecalith was suspected to have been produced at the site of a large diverticulum in the transverse colon. The fecalith was surgically resected, and a histological diagnosis of pseudodiverticulum was made. There was no recurrence during 33 mo of follow-up.CONCLUSIONThis case highlights the importance of accurate identification and treatment of a fecal impaction. This case indicated that the endoscopic evacuation and subsequent colonography were effective for identifying a diverticulum that might have caused fecal impaction. A fecal impaction was associated with the diverticulum. Consequently, the planned diverticulectomy was performed. Appropriate emergency medical treatment and maintenance treatments should be selected in such cases to prevent recurrence.

Errors and сomplications in the treatment of children with anorectal malformations

Purpose. This manuscript aims to introduce errors and complications of diagnosis and treatment in children with anorectal malformations (ARM).
 Methods. A retrospective analysis of 63 children with ARM treated at a single tertiary Speransky childrens Hospital.
 Results. The patients ages ranged from 2 mo to 17 y. o. (median, 6 y. o.). The types of ARM included: rectourethral fistula 27%, rectoperineal fistula 17.5%, rectovestibular fistula 15.9%, rectobladderneck fistula 6.3%, no fistula 7.9%, cloaca 11.1%, cloaca with urogenital sinus and disorder of sex development 1.6%, pouch colon 1.6%, rectal stenosis 4.8%, anal duplication 3.2%, and rectovaginal fistula 3.2%. Of these patients, 76% underwent surgery earlier at another hospital (surgical treatment completed), 14% had stomas, and 10% did not have any prior procedures. The historical analysis showed diagnostic errors in 48% of children (untimely diagnosis, incorrect interpretation of the ARM variant, prolonged delay in anorectoplasty). Errors led to emergency procedures or changes in subsequent surgical treatment (further ostomy, excess bowel resection) in 22% of cases. After anorectoplasty (stenosis, mislocated anus/rectum, rectal prolapse), complications were detected in 56% of cases, whereas ostomy complications were observed in 5% of cases. Long-term problems after the surgical treatment (constipation, incontinence, and pseudoincontinence) were evident in 98% of children. Different surgical reconstructive techniques of the sphincter formation had been performed previously in 13% of patients. Moreover, they most often had spinal pathology as the cause of functional disorders. Only half of the childrens parents had information about bowel management, 38% did not follow the recommendations and usually had fecal impaction and pseudoincontinence. 45% of children/parents performed non-effective or irregular enemas and required corrective treatment.
 Conclusion. It is recommended that Russian pediatric surgeons treat children with ARM, according to Russian pediatric surgeons guidelines consistent with international protocols to avoid errors and complications.

Only mass migration of fungi runs through the biotopes of soil, phyllosphere, and feces

Understanding the microbial linkages among the soils, plants, and animals is crucial for maintaining the balance of the grazed grassland ecosystem. However, previous studies always focused on the biotopes of soil, phyllosphere, and feces separately and little has been known about microbial distributions and migrations among these biotopes. In this study, systematic surveys about the overlap and differentiation among various microbiotas of biotopes and how the environmental filter on microorganisms served for the ecosystem were conducted. Soil, phyllosphere, and feces samples were collected from grazed and ungrazed grassland in Inner Mongolia, China. High-throughput sequencing and qPCR were employed to obtain the genome data. The results were analyzed by various statistical tools such as genomic analysis and machine learning classification to describe the disparities and linkages among the microbiotas of three biotopes. Our findings revealed that the biotopes drove the distinct microbial community assemblages with various richness, β-diversity and composition. The substantial overlaps between soil and phyllosphere in fungi, bacteria and archaea indicated that soil played the role of the microbial source for the phyllosphere. Communal OTUs could be found between phyllosphere and feces. Nevertheless, Ascomycota were the only microorganisms migrating among all the biotopes massively. After the long-term impact of feces via grazing, the soil and phyllosphere microbiota also altered significantly. Biotopes drive the discrepancy of microbiota distribution among the soil, phyllosphere, and feces. Soil could potentially perform as the microbial reservoir for the phyllosphere. The phyllosphere plays the role of bridge to link soil and feces biotope through its fluctuated condition. However, there was only fungal migration running through the ecosystem to link all the biotopes. These findings promoted our understanding of the biotope contribution to microbial migration and improved the knowledge of microbial linkages in the grazed grassland ecosystem.

Overflow diarrhea and acute kidney injury as a presentation of fecal impaction that led to obstructive uropathy

Fecal impaction is a known complication of chronic constipation and is particularly bothersome in the elderly population. Common complications of fecal impaction include hemorrhoids, megacolon, overflow diarrhea, and obstructive uropathy among others. Many case reports have been reported with fecal impaction and obstructive uropathy though none have reported overflow diarrhea as a presentation. In this case report, we present an elderly male who came in with overflow diarrhea and acute kidney injury that resulted from fecal impaction that caused obstructive uropathy. He was managed with catharsis and early recognition of the condition led to a good outcome. Recognition and management of fecal impaction can be challenging especially in patients who present with diarrhea. We, therefore, outline and discuss the importance of recognition of overflow diarrhea as a complication of fecal impaction and the management of such patients.

Loaded colon causing death: A case report

Colon can be loaded with faecal matter following acute or chronic constipation. Most of the time it can be relieved with medical or surgical interventions. Rarely does it produce complications due to perforation by impacted stool causing peritonitis and sepsis. Here we came across the case of a young female who is brought dead to casualty following vomiting and abdominal pain. The medico legal autopsy showed a hugely dilated colon loaded with faecal matter causing respiratory and cardiovascular compromise due to the pressure effect on thoracic structures. The cause for the constipation in this case was an imperforated anus at birth which was operated in childhood itself but was not cured completely. We could hardly get this kind of complication with faecal impaction from literature as there are very few reported cases.

Neuroleptiques Causing a Giant Abdominal Mass

A 39 years old patient was admitted to our hospital, never operated before, with a history of mental illness. The patient was treated for schyzophrenia since the age of 15, under a long term treatment of neurolyptics and antidepressants, with complaints of chronic constipation. The patient reported abdominal pains and cessation of stool and gas, no defectation in 15 days, along with continuous vomitting.The patient was concious, instable TA : 80/40mmHG FC: 120B/m FR : 22 c/m. On initial evaluation we could detect an important abdominal distention as well as an apparent venous collateral circulation accompagnied with tenderness to palpation [Figure A]. Rectal examination revealed the presence of a very hard fecaloma. The initial biological assessment showed functional renal insufficiency, Hyperleukocytosis at 11000 /mm3, hyponatremia at 125 mmol/L. Abdominal tomography revealed a giant fecaloma at the rectum, the sigmoid and the left side of the transverse colon, and a mega colon with a diametre reaching 22 cm wide, the lining of the colon was improperly enhanced after the injection of the contrast agent [Figure B]. The patient was then admitted to the trauma room, he was prepared with a rehydration and hydro-electrolytic compensation. Repeated enemas and laxatives were used to stimulate defectation, but they were all unsuccessful, the hard mass of stool could not be removed. It was decided that the patient required abdominal surgery. Under general anesthesia, patient in supine position, a midline laparotomy was performed. During the exploration, we discovered a colon filled with a giant ficaloma, along with ischemic parietal lesions on the sigmoid [Figure C].
 Resection of the descending and sigmoid colons, manual extraction of the remainder of the fecalomas from the rectum, and terminal colostomy were performed following Hartmann's technique. The patient remained instable even after being treated in intensive care, the patient unfortunately passed away 48 h post operation.
 Constipation is a common problem that can cause fecal impaction and even development of a fecaloma, a mass of inspissated stool. Fecalomas occur more frequently in the left colon and rectum as stool hardens and the colon narrows. Fecalomas can manifest in various ways including bowel obstruction, urinary retention, and toxic megacolon.
 Medica­tions that were significantly associated with constipation were opioids, diuretics, antidepressants, antihistamines, antispasmod­ics, anticonvulsants, and aluminum antacids. The use of acetaminophen (>7 tablets weekly), aspirin, and other NSAIDs was also found to be associated with an increased risk of constipation. Fecalomas can often be treated conservatively with laxatives, enemas, and/or digital disimpaction. However, when these methods are unsuccessful, surgical intervention is required to prevent bowel perforation.
 In patients with history of constipation, new or worsening of abdominal pain, and are under antidepressants and neurolyptic treatment, fecalomas should be considered in the differential diagnosis, and constipation should be aggressively investigated to avoid complications.

Evaluation of the Anti-constipation Effects of Abdominal Application of Olive Oil Ointment in Children 1-4Years Old: A Pilot Placebo-Controlled, Double-Blind, Randomized Clinical Trial.

With a prevalence of 0.7 to 29.6%, functional constipation (FC) is a common pediatric complaint worldwide. Current therapeutic strategies for FC mainly include prevention and treatment of fecal impaction, by administration of oral laxatives or rectal medications. However, these agents have been reported to have limited efficacy and a number of serious side effects. In traditional Persian medicine, local application of olive oil was used to relieve childhood constipation. In this pilot placebo-controlled, double-blind, randomized clinical trial, the laxative effects of the external use of olive oil ointment in 1- to 4-year-old children with functional constipation were investigated. Forty patients with FC were randomly assigned in olive oil ointment or placebo groups, receiving either an ointment containing 85% olive oil or a comparable placebo or an ointment containing 85% liquid paraffin adjusted to have color and odor similar to those of intervention ointment, twice a day for 4days. Rome III criteria for functional gastrointestinal disorders (FGIDs) were used to identify eligible patients from three hospitals. The primary outcome measure was treatment success, defined as ≥1 spontaneous stools per day, without episodes of fecal impaction at endpoint (day 4). The secondary outcome measure was the frequency of fecal incontinence, abdominal discomfort or flatulence, painful defecation, and dermal irritations (adverse effect). Improvements in stool frequency started from day 1 and continued up to day 4 (end of the study) and were significantly greater in patients receiving olive oil ointment in comparison with placebo group (p<0.05). No adverse effect (including fecal incontinence, painful defecation, gripe and skin reaction, etc.) was reported in intervention and placebo groups during the study. Olive oil ointment used in this study can be presented as a safe, well-tolerated, and effective herbal preparation in children with functional constipation.

Surgical Excision of Perirectal Melanoma in the Horse. 3 Cases

Equine melanoma is one of the most common skin neoplasms encountered in equine practice. Surgical excision of melanocytic tumors is a viable treatment option and is considered to be locally curative. In the literature, information regarding surgical removal and long-term outcome of perirectal melanomas is limited. A total of three cases were included in this report, all presented with large perirectal melanomas, infiltrating the retroperitoneal musculature, leading to extra-luminal obstruction of the rectum. Horses were showing signs of dyschezia and tenesmus, secondary to rectal fecal impaction. Rectal palpation and transrectal ultrasonography aided in assessing the depth and size of the masses, as well as tumor invasion into the rectal wall. Tumor biopsy by fine needle aspiration was used to confirm the diagnosis. All horses underwent surgical excision of the masses to permanently alleviate clinical signs. In one horse, complete incision and reconstruction of the rectal wall was necessary in order to excise the whole tumor. Although surgery was successful in all three horses, one of them had to be euthanized 5 days after surgery, as clinical signs persisted. The aim of this report was to extensively describe the surgical approach, pre-operative considerations and postsurgical complications associated with surgical excision of perirectal melanoma in the horse.

Fecal impaction is associated with postoperative urinary retention after hip fracture surgery.

Postoperative urinary retention (POUR) is a common hip fracture (HF) complication. Although fecal impaction (FI) is one of the oft-cited causes of POUR in clinical practice, evidence regarding this association is scarce. The aim of this study was to determine whether FI was associated with POUR after HF surgery in older patients. All patients consecutively admitted after a HF surgery in a geriatric perioperative unit were included in this cross-sectional study. FI was systematically assessed by a digital rectal exam at admission and according to clinical suspicion during the hospital stay. The dependent variable was POUR, systematically screened according to the department protocol and defined as a bladder volume>400ml requiring catheterization. The association between FI and POUR was assessed by multivariable analysis. A total of 256 patients were included (mean [SD] age 86 [6] years), (76% women): 108 (42%) presented FI and 63 (25%) POUR. The frequency of FI was higher with than without POUR (73% vs. 32%, P<0.001). On multivariable analysis, after adjusting for age, sex, Cumulative Illness Rating Scale score and anticholinergic load, FI was the only factor independently associated with POUR (odds ratio 4.78) [95% confidence interval 2.44-9.71], P<0.001. FI was the only independent factor associated with POUR after HF surgery in older adults. Further studies are needed to optimize perioperative geriatric care including FI and POUR assessment and management.

Anemia normocitica e dosaggio degli ormoni tiroidei

The paper describes the case of an 11-year-old girl presenting with normocytic hyporegenerative anaemia associated with increase of transaminases, CK and LDH. On physical exam skin pallor, mask-like facies and dry skin were observed; weight and height were below the third percentile for age and sex. Abdomen ultrasound (US) was significant for faecal impaction, but excluded an abdominal neoplasia. Lab tests showed persistency of normocytic anaemia while B12 and folate dosage, haemoglobin electrophoresis and DEB test were normal. However, a screening of thyroid function showed an abnormally high TSH and undetectable fT4 and fT3. Dosing of specific antibodies and thyroid US led to diagnosis of Hashimoto thyroiditis. Normocytic anaemia among paediatric patients cannot only be related to medullary aplasia, but also to chronic diseases and endocrinological disorders that should be adequately investigated. If the diagnosis still remains elusive, the execution of a bone marrow is mandatory.

Abdominal compartment syndrome due to extremely elongated sigmoid colon and rectum plus fecal impaction caused by disuse syndrome and diabetic neuropathy: a case report and review of the literature

BackgroundAbdominal compartment syndrome (ACS) is defined as a sustained raised level of intra-abdominal pressure more than 20 mmHg with or without abdominal perfusion pressure less than 60 mmHg and the development of new end-organ failure. Abdominal surgery, major trauma, volvulus, ileus, distended abdomen, fecal impaction, acute pancreatitis, liver dysfunction, sepsis, shock, obesity, and age have all been reported as risk factors. Herein, we report the severest known case of ACS due to extremely elongated sigmoid colon and rectum plus fecal impaction caused by disuse syndrome and diabetic neuropathy, together with a brief review of the literature.Case presentationA 48-year-old Asian man suffering from shock was transported by ambulance to our hospital. His medical history included hypoglycemic encephalopathy sequelae, disuse syndrome, type 2 diabetic neuropathy, and constipation. He recovered consciousness in the ambulance, and his physical examination as well as laboratory findings were normal. X-ray and dynamic computed tomography revealed a thickened gut wall, and an extremely dilated sigmoid colon and rectum filled with a massive amount of stool as well as gas, compressing other intra-abdominal organs. We diagnosed the patient with transient vasovagal syncope, together with ACS, due to extremely elongated sigmoid colon and rectum plus fecal impaction, caused by anorectal disturbance derived from disuse syndrome and diabetic neuropathy. We first repeated stool extraction for bowel decompression and he subsequently became symptom-free, after which we performed a colostomy on the 28th hospital day. The postoperative course was uncomplicated, and he was discharged on the 44th hospital day.ConclusionsClinicians need to keep ACS in mind as a differential diagnosis and perform careful and detailed examination when encountering patients presenting with symptoms or risk factors of ACS. In addition, they need to precisely diagnose ACS and perform optimal treatment without delay.

Obstructive Colitis with Minor Perforation Induced by Double Sigmoid Adenocarcinoma.

A 72-year-old women was referred to our hospital because of lower left abdominal pain. Computed tomography showed prominent sigmoid colon dilation and double tumors on both the oral and anal sides. Surgical resection revealed an expanded sigmoid colon involved in double cancer that showed strong adhesion to the surrounding tissues. The pathological findings revealed obstructive colitis and minor perforation in the dilated colon. The minor perforation was considered to have been caused by fecal impaction in the closed cavity between the two tumors, resulting in an increase in colon pressure.

Ischemic proctitis complicating fecal impaction.

Ischemic proctitis complicating fecal impaction.

Rehabilitation of neurogenic bladder and bowel after spinal cord injury

Neurogenic bladder and bowel refers to the dysfunction of bladder and bowel caused by neurogenic etiology. Spinal cord injury is a major cause of this dysfunction, which seriously affects the injured person’s quality of life. The injury causes not only motor weakness of abdominal and perineal muscles, but also sensory changes and autonomic dysfunction of bladder and bowel. Spinal cord injuries involve multiple systems, and thus affect the normal functioning of the bowel and bladder in several ways: difficulty in urination and defecation, frequent or infrequent voiding, decrease of the sensation of fullness, incontinence, autonomic dysreflexia, perineal hygiene, deterioration of renal function, fecal impaction, psychological burden, etc. Thus, this review aims to provide updated practical guidance for the evaluation and management of neurogenic bowel and bladder by the clinicians who want to provide better care for their patients. Management of neurogenic bowel and bladder starts with carefully recording the patient’s history, including their bowel habits prior to the spinal injury. In general, evaluation of the neurogenic bladder requires more clinical tests than for the neurogenic bowel. The patients’ problems can be alleviated by adopting various measures: proper daily water and food intake, simultaneous pharmacologic treatments for the bowel and bladder, physiologic reflexes, bladder catheterization, rectal irrigation, surgical measures, etc. Priority should be given to the management of the neurogenic bladder with clean intermittent catheterization and decompression of the bladder pressure, and management of the neurogenic bowel by pharmacological treatment.

S3374 Overflow Diarrhea and AKI as a Presentation of Fecal Impaction That Led to Obstructive Uropathy

INTRODUCTION: Fecal impaction is a known complication of chronic constipation and is particularly bothersome in the elderly. Common complications of fecal impaction include hemorrhoids, megacolon, overflow diarrhea and obstructive uropathy among others. Overflow diarrhea is often misdiagnosed and treated with antidiarrheal medications leading to further worsening of impaction. Obstructive uropathy is a well-established complication of fecal impaction with obstruction occurring at any level of the urinary tract. Children and young adults are at high risk as are the elderly due to multiple risk factors including but not limited to diabetes mellitus, dementia, opioid use and depression. Many case reports have been published with fecal impaction and obstructive uropathy though none have reported overflow diarrhea as a presentation. CASE DESCRIPTION/METHODS: An 82-year-old male patient presented with diarrhea and acute kidney injury that was caused by fecal impaction that led to obstructive uropathy. He had a 4-week history of non-bloody watery diarrhea with associated fecal incontinence and generalized abdominal pain. He reported a long-standing history of constipation prior to this. Generalized abdominal tenderness with mild diffuse distention and a distended urinary bladder were noted on exam, along with normal rectal tone with loose brown stool in absence of hemorrhoids or prostate enlargement. Lab work showed elevated creatinine and hypokalemia. Upon IV fluid resuscitation and foley catheter placement, CT abdomen was done which showed bilateral hydronephrosis. Stool studies showed no evidence of infection. He was managed with laxatives and had significant improvement in kidney function as well as significantly reduced stool burden. DISCUSSION: Our patient had multiple risk factors for impaction including age, immobility, diabetes, and medications including azacitidine. Chronic constipation in our patient led to fecal impaction which eventually led to overflow diarrhea and obstructive uropathy. It is important to consider impaction as a cause of fecal incontinence and diarrhea in the elderly as it can lead to high morbidity and mortality. The treatment of this diarrhea is counter-intuitive since the impaction benefits from catharsis not antidiarrheals. Diet counseling, biofeedback, and rarely surgical intervention can be used in refractory cases.Figure 1.: Computed Tomography imaging showing bilateral hydronephrosis (A) and dilation of rectum (B).Figure 2.: Computed Tomography imaging showing improvement in hydronephrosis and stool burden post catharsis.

S3402 Toxic Megacolon Disguised as Fecal Impaction

INTRODUCTION: Clostridium difficile colitis is a disease rising in incidence over the years with increasing mortality, especially with complications such as toxic megacolon which can affect 0.4-3% of cases. This case report shows the need to keep a high index of suspicion, especially with atypical presentations to help reduce the mortality rate. CASE DESCRIPTION/METHODS: A 77 year old male with a history of Alzheimer’s Disease had a prolonged hospital course after admission for a fracture requiring surgery after a ground level fall. One and a half month into the hospital course, the patient was diagnosed with suppurative parotitis with associated leukocytosis up to 33,000. He was begun on empiric antibiotics which were eventually de-escalated to daptomycin & zosyn with subsequent resolution in leukocytosis one week into the planned two week antibiotic course. On the last day of antibiotics, patient was noted to having uptrending leukocytosis up to 24,000 despite staying afebrile, vitally stable, and with no symptoms reported including abdominal pain or diarrhea. His antibiotics were escalated with continued worsening of leukocytosis up to 42K. At that time, patient began complaining of abdominal pain with subsequent CT scan noting significant colonic stool with possible fecal impaction. Given the leukocytosis and imaging, he was evaluated by surgery due to concern of possible perforation. Surgery had low concern for perforation and recommended aggressive bowel regimen after which patient began stooling frequently. Shortly thereafter, he became hypotensive requiring vasopressor support. He subsequently tested positive for clostridium difficile and was begun on treatment for fulminant C. difficile with toxic megacolon. However, the patient died a few days later. DISCUSSION: C. difficile colitis and its complications, including toxic megacolon, are important to recognize early to ensure prompt treatment of this potentially fatal disease. There are the known expected signs and symptoms including abdominal pain, diarrhea, fevers, lactic acidosis, elevated creatinine, significant leukocytosis. However, it is important to not be confounded by unusual presentations such as in this case. Other rare case reports include Burke et al. who describe a patient with toxic megacolon from C. difficile without diarrhea. Malkan et al. also describe a case series of uncommon presentations though most are noted to have known risk factors including prolonged hospital or antibiotic courses.