Severe Fecal Impaction Research Articles

Pathological post-obstructive diuresis following obstructive uropathy due to constipation in the post-partum period: a case report

BackgroundConstipation during pregnancy is not uncommon. Usually, this does not warrant extensive evaluation and settles with minor interventions or lifestyle modifications. Severe fecal impaction in chronically constipated patients can rarely lead to obstructive uropathy. Relief of obstruction can result in a diuretic phase which may be self-limiting or pathological. However, occurrence of pathological post-obstructive diuresis as a result of severe constipation is an extremely rare complication during pregnancy and puerperium which can even be fatal if not promptly diagnosed and adequately monitored and timely intervened. We describe the management of a pathological post-obstructive diuresis which occurred in the immediate postpartum period after treatment of severe constipation and obstructive uropathy.Case presentationA woman who had undergone an emergency caesarean section due to deep transverse arrest 1 week ago, presented with fecal impaction and anuria. On relief of urinary obstruction which had developed secondary to fecal impaction, she developed pathological post-obstructive diuresis. Careful and timely monitoring with exact fluid replacement, correction of electrolyte imbalances and multidisciplinary care ensured complete recovery of the patient.ConclusionsDespite obstructive uropathy being uncommon in obstetric practice, clinicians need to have a high index of suspicion to monitor and promptly manage the potentially life-threatening condition of post-obstructive diuresis in pregnant and puerperal women undergoing urinary tract decompression. Due to unreliability of laboratory cutoff values in pregnancy and puerperium, a more vigilant and multidisciplinary approach with lower threshold for intervention is more prudent in the management of these patients.

A fatal fecaloma

BackgroundFecal impaction may complicate chronic constipation. We report a fatal case of fecal impaction in a patient treated with long-term neuroleptic treatment.Case presentationA 70-year-old man with a history of severe chronic psychosis treated with olanzapine was admitted to the emergency department for acute abdominal pain and increased abdominal perimeter. Abdominal computed tomography revealed a severe fecal impaction with no sign of peritonitis or acute mesenteric ischemia. The patient eventually died from multi-organ failure 2 days after his admission to the intensive care unit.ConclusionsChronic constipation with fecal impaction is a well-known complication of long-term neuroleptic treatment. Severe forms may be life-threatening. Prevention with systematic administration of laxatives appears of paramount importance.

Deep Vein Thrombosis Due to Fecal Impaction

Deep vein thrombosis (DVT) can occasionally be secondary to mechanical compressions, such as in May-Thurner syndrome. To our knowledge, no cases of DVT associated with mechanical compression by fecal impaction in a pediatric patient have been previously reported. An 18-year-old developmentally delayed female presented to the emergency department with swelling involving her left lower extremity. Cross-sectional imaging revealed a significant stool burden in the rectosigmoid colon compressing the left external iliac vein and causing secondary thrombosis. Thrombectomy successfully alleviated the clot burden. This case underscores the potentially serious implications of severe fecal impaction in the pediatric and adolescent populations.

3059 A Serious Case of Fecal Impaction

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.

The use of intravenous neostigmine in palliation of severe ileus.

Neostigmine is a parasympathomimetic drug that acts as a reversible acetylcholinesterase inhibitor. Clinically it is used in patients with acute colonic pseudo-obstruction (ACPO or Ogilvie's syndrome, which is a gastrointestinal motility disorder characterized by marked dilatation of the colon in the absence of mechanical obstruction), postoperative ileus, urinary retention, myasthenia gravis, and in anesthesia to reverse the effects of nondepolarizing muscle relaxants. Both bolus and infusion are noted to be effective and lead to prompt evacuation of flatus or stool with a reduction in abdominal distention on physical examination. Median duration is noted to be 4–30 minutes in some trials. Here we present our experience of using 2 mg of intravenous neostigmine to help relieve the severe abdominal distention and ileus in a patient with severe fecal impaction when all conservative measures had been futile. The most frequent side effect of the drug is abdominal pain/cramping, which was noted in our patient as well. Other complications include bradycardia which is very infrequently symptomatic to require atropine. Overall, the drug is a simple, safe, and effective strategy; and as pointed out in the previous studies, the drug appears to be underused in patients who do not have a true contraindication to its use.

Abdominal a-lines: a simpler sonographic sign of pneumoperitoneum?

An 82-year-old female presented to the emergency department with abdominal distension, decreased mental status and a report of no bowel movement for 4 days. She had multiple medical problems including severe dementia. On arrival, she was lethargic but arousable to pain. Her vital signs were normal except for an elevated blood pressure (196/93 mmHg). Her abdomen was severely distended, diffusely tender and suspicious for deep crepitus. A bedside ultrasound was performed using a curvilinear, low-frequency probe. No abdominal structures were visualized in any area of the abdomen (Fig 1). A second scan was performed using a high-frequency linear probe in the exact same spot as Fig. 1 which showed multiple, equally spaced, horizontal, hyperechoic lines repeating down the screen without any visualization of abdominal organs (Fig. 2). No such lines were seen with the curvilinear probe. This pattern was very similar to the common ‘‘a-lines’’ seen in thoracic ultrasound (Fig. 3). Her X-ray confirmed the sonographic diagnosis of massive pneumopeitoneum. She had severe fecal impaction causing colonic perforation. The patient’s family requested comfort care only and she was discharged to hospice. Ultrasound can detect as little as ‘‘a single tiny bubble’’ of air in the abdominal cavity [1] and the ultrasonic findings of pneumoperitoneum have been well described: echogenic free-fluid, focal hyperechoic bubbles, ring-down artifacts that shift with patient position, ‘‘dirty shadowing’’ and enhancement of the peritoneal stripe with or without a reverberant echo [2–4]. Many of these are subtle findings requiring a certain degree of expertise to detect (Fig. 4). a-Lines are well known and easily obtained artifacts found in thoracic ultrasound [5]. They arise as a result of a reverberation of the sound waves hitting the strongly reflective pleura, which is superficial to either a well-aerated lung or a pneumothorax. The lung, itself, is not visualized as the air beneath the pleura attenuates the sound waves. Higher frequency probes cause greater attenuation. The ‘‘lung’’ that appears on the screen is merely multiple repetitions of the skin-to-pleura image, a reverberation artifact. The abdominal a-line has not been previously labeled as such and results from the same mechanism as its thoracic counterpart. The multiple, equally spaced, horizontal lines represent repetitions of the skin-to-parietal peritoneum image and the abdominal organs are not visualized due to the attenuation of the sound waves by the free intra-peritoneal air beneath. Images should be obtained with the patient supine using a linear, high-frequency probe. Different areas of the abdomen should be interrogated to lessen the likelihood of a false-positive exam due to bowel gas. With this technique, abdominal a-lines may be easier to obtain than some of the other known sonographic findings of pneumoperitoneum. For example, our image shows the classic ‘‘thickened peritoneal stripe’’. Unless the sonographer has spent time studying normal peritoneal thickness, this finding could easily be missed. The abdominal a-line is far more obvious. The many sonographic findings of pneumoperitoneum have been shown to be more sensitive and equally specific to those of X-ray [6]. Further work needs to be done to correlate the presence and size of abdominal a-lines with the J. Scott Bomann (&) R. Van Tonder S. Hernandez C. Moore Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Avenue, Suite 360, New Haven, CT 06519-1315, USA e-mail: sbomann@msn.com

Report of an Unusual Case With Severe Fecal Impaction Responding to Medication Therapy

Fecal impaction is a disorder characterized by a large mass of compacted feces in the rectum and/or colon, which cannot be evacuated. For mild and moderate fecal impaction, recommended treatments include stool softeners, oral mineral and olive oil, and edema; for severe fecal impaction, manual removal is needed and sometimes laparotomy may be indicated if medical therapies are not effective. Here we report a case with severe fecal impaction who did not defecate for 75 days. We treated this patient with vegetable oil, Chinese traditional medicine and enema in sequence. After 12 days of therapy, she evacuated hard fecal masses, and the symptoms were relieved.

Hepatic derangement following N-Acetylcysteine enemas in an infant with cystic fibrosis

We discuss an infant with MI secondary to cystic fibrosis, who was managed surgically by a double barrel ileostomy for mid - small bowel atresia and developed severe faecal impaction in the post - operative period. The faecal impaction was treated successfully with oral NAC and 0.2% NAC contrast enemas. The patient's liver function tests revealed a dramatic increase in transaminases and bilirubin contemporaneous with the administration of the enemas. The levels showed a spontaneous improvement after discontinuation. This is only the second reported case of hepatotoxicity secondary to NAC enemas in the literature. While our experience offers modest support for the use of NAC, its efficacy is not yet proven and paediatric surgeons using NAC in the enema form need to closely monitor liver function contemporaneous with this agent's administration and adjust their treatment accordingly.

Life-Threatening Constipation Associated with Clozapine

The aim of this paper was to describe the association of clozapine with life-threatening constipation. Case report. A 53-year-old man presented to the emergency department with severe abdominal pain and bilious vomiting after being on clozapine for over a year for schizoaffective disorder. Surgery revealed severe faecal impaction in the large and small bowel. Clozapine was ceased. There were significant difficulties in the subsequent psychiatric management. Clozapine was gradually reintroduced with concurrent laxative administration, which resulted in another episode of severe constipation with faecal impaction. Clozapine can be associated with potentially life-threatening constipation. Psychiatrists, especially consultation liaison psychiatrists, physicians, surgeons and radiologists, should be aware of the seriousness of clozapine-induced constipation and its potentially fatal complications.

Fecal Impaction and Systemic Inflammatory Response Syndrome in A Young Male with Cerebral Palsy

Symptoms of fecal impaction extend from constipation, anorexia, nausea, vomiting and abdominal pain, to full blown sepsis. We present the case of a patient with cerebral palsy and mental retardation, who presented to the Emergency Department with a 3-day history of diffuse abdominal pain and fecal incontinence. Evaluation revealed severe fecal impaction. The patient developed systemic inflammatory response syndrome (SIRS), with negative workup for underlying etiology. He responded well to digital disimpaction and antibiotics. Our case illustrates the serious sequelae of fecal impaction, which should be considered in patients with neurologic disorders and SIRS.

Evaluation of polyethylene glycol plus electrolytes in the treatment of severe constipation and faecal impaction in adults

ABSTRACTIntroduction: Extreme and severe cases of constipation can lead to faecal impaction. Current therapies are often both ineffective and unpleasant. The objective of this trial was to evaluate the efficacy and safety of Movicol, a polyethylene glycol (PEG) + electrolyte solution (PEG+E), as treatment for severe constipation and faecal impaction.Patients: 56 patients (aged 17 to 88 years) with a history of chronic constipation and presenting with no bowel movement for three to four days (severe constipation), or no bowel movement for at least five days (faecal impaction), were enrolled at three centres in Taiwan. Faecal loading was confirmed in all patients by abdominal and rectal examination or abdominal radiography. Patients were excluded from the study if they had a gastrointestinal obstruction, evidence of delayed gastric emptying, or if their constipation was secondary to severe inflammatory bowel disease.Treatment: All patients followed the same regimen: up to eight 13.8 g sachets of PEG+E (two at a time in 250 ml water; maximum of 1 L/day) over a 4–6 h period each day, with 1–1.5 h between each dosing. Duration of treatment was for up to three days.Efficacy endpoints and results: Patients with either improvement (passage of a moderate to large volume of stool within four days of treatment initiation) or complete resolution (passage of moderate to large volumes of faecal matter plus the disappearance of palpable faecal masses in the abdomen and/or rectum) were considered responders. Based on bowel movement data recorded by the patients, an excellent response rate was obtained: 50/56 patients had a successful response to treatment (89.3%; 95% confidence intervals [CIs] 77.4% to 95.6%); there were 39 complete responders and 11 patients showed improvement. Investigator assessment of response was almost the same: 87.5% (95% CIs 75.3% to 94.4%). All bowel movement measurements (stool volume, number of evacuations, stool form and ease of evacuations) showed a positive improvement by Day 2. Median duration of treatment was two days. The incidence of adverse events was low, even for those side-effects such as abdominal pain and bloating, which are known undesirable consequences of PEG+E administration. No patient discontinued from the study because of an adverse event.Conclusion: PEG+E, administered orally at a dose equivalent to eight 13.8 g sachets (1 L) per day over three days, was a highly effective and well tolerated therapy for the treatment of severe constipation and faecal impaction.

Movicol in treatment of constipation and faecal impaction.

To resolve severe constipation or faecal impaction requires the induction of a large increase in faecal water content that hitherto has only been achieved with enemas. A novel iso-osmotic laxative has been shown to achieve a similar effect from oral dosing.

Fecal impaction

Cardiopulmonary arrest in childhood is usually due to respiratory failure leading to hypoxemia, acidosis, cardiac dysfunction, and terminal asystole. Respiratory failure is the end result of either impaired oxygenation, impaired ventilation, or both. We report a case of severe fecal impaction in an eight year old that resulted in a significant depression of ventilation by severely restricting respiratory mechanics and that ultimately progressed to respiratory failure and circulatory compromise. Physicians should be aware of this rare but possible etiology for life-threatening events in children.

Treatment of fecal impaction with pulsed irrigation enhanced evacuation.

A new method of treating fecal impaction is described, selecting patients that would otherwise have required operative disimpaction. Using the pulsed irrigation enhanced evacuation device, individuals were selected for treatment based on evidence of massive fecal impaction on physical examination or abdominal x-ray. Fourteen individuals were treated for fecal impaction. The patients ranged in age from 13 to 86 years. Only one patient required intravenous sedation, an elderly patient with Alzheimer's disease. The treatment was successful in each case, although repeated treatment was often necessary. No morbidity arose from the treatment. By the midpoint in our study, because of the success of this treatment, no patient required hospitalization for impaction. Pulsed irrigation enhanced evacuation has been in our experience a simple, quick, and effective treatment for severe fecal impaction.

Use of dioctyl sodium sulfosuccinate (aerosol O.T.) for severe constipation.

The purpose of this communication is to direct attention to the usefulness of dioctyl sodium sulfosuccinate (Aerosol O. T.), developed some 15 years ago, in the treatment of severe fecal impaction and lesser degrees of constipation. As one of the very first of the synthetic wetting agents it was originally popularly described in Life magazine without implication of medical usefulness, and readers may recall that its remarkable properties were illustrated by the cover picture of a duck sinking in water to which a small concentration of this material had been added. The effectiveness of this material for treating constipation is consequent to its ability to allow a hard fecal mass to be penetrated by water or by mineral oils so that it becomes effectively softened. Its action thus seems to be the simple physical effect one would expect From the Department of Pediatrics, University Hospital. The food absorption studies were