Pooping Normal Again After Passing Impacted Stool
Clin Colon Rectal Surg. 2005 May; xviii(ii): 116–119.
Constipation and Functional Bowel Disease
Guest Editor David Due east. Beck M.D.
Fecal Impaction
Farshid Araghizadeh
1Section of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
ABSTRACT
Fecal impaction is a mutual gastrointestinal problem and a potential source of major morbidity. Prompt identification and handling minimize the risks of complications. Treatment options include manual extraction and proximal or distal washout. Following treatment, possible etiologies should exist sought and preventive therapy instituted.
Keywords: Fecal impaction, constipation
Fecal impaction is a common gastrointestinal disorder and a source of pregnant patient suffering with potential for major morbidity.1 Despite a multimillion dollar laxative industry in our bowel-conscious social club, fecal impaction remains an overlooked status. The incidence of fecal impaction increases with age and dramatically impairs the quality of life in the elderly.2 Read and colleagues found that 42% of patients in a geriatric ward had a fecal impaction.iii
ETIOLOGY AND PATHOPHYSIOLOGY
The etiologic factors responsible for constipation can also lead to fecal impaction as an acute complication. Nearly of these factors are listed in Table 1.two , 4 Ane of the almost of import gamble factors is inadequate dietary cobweb and water. An increase in fiber intake to 30 chiliad/solar day coupled with acceptable hydration helps foreclose constipation and fecal impaction by poorly diluted cobweb. Lack of mobility considering of aging or spinal cord injury may besides cause fecal impaction related to reduction of colonic mass movements and an inability to use abdominal muscles to assistance in defecation. Medications known to retard gastrointestinal move include opiate analgesics, anticholinergic agents, calcium channel blockers, antacids, and fe preparations.2 Paradoxically, laxative abuse is associated with constipation and fecal impaction. The laxative-dependent patient is unable to produce a normal response to colonic distention and progressively requires higher doses to achieve a bowel motion.v Congenital and acquired weather condition of the colon and rectum, including Hirschsprung'south affliction and Chagas' disease, tin can also cause fecal impaction.6 In improver to these etiologic factors, anatomic and functional abnormalities of the anorectum should be considered and excluded.7
Tabular array ane
Etiologies of Fecal Impaction
| Chronic constipation |
| Anatomic |
| Metabolic |
| Dietary |
| Medications |
| Neurogenic |
| Anatomic anorectal abnormalities |
| Megarectum |
| Anorectal stenosis |
| Neoplasm |
| Functional anorectal abnormalities |
| Increased rectal compliance |
| Abnormal rectal sensation |
CLINICAL PRESENTATION AND EVALUATION
The typical presenting symptoms of fecal impaction are like to those constitute in intestinal obstruction from any crusade, including abdominal pain and distention, nausea, airsickness, and anorexia.vi These are summarized in Table 2.ii A retrospective review by Gurll and Steer revealed that 39% of patients with fecal impaction had a history of prior impactions.8 These symptoms result from hardened stool impacted in the rectum or distal sigmoid colon with subsequent obstruction. Additional complications such as stercoral ulceration, rectovaginal fistula, megacolon, and colonic perforation may ensue.nine Elderly or institutionalized patients with dementia or psychosis may nowadays with paradoxic diarrhea and fecal incontinence.vi
Tabular array ii
Symptoms Associated with Fecal Impaction
| Constipation |
| Rectal discomfort |
| Anorexia |
| Nausea |
| Vomiting |
| Abdominal pain |
| Paradoxic diarrhea |
| Fecal incontinence |
| Urinary frequency |
| Urinary overflow incontinence |
Following a complete history and concrete examination, plain abdominal films are indicated to search for intraluminal feces or signs of obstruction (Fig. 1). The presence of bowel obstacle as evidenced by dilated small bowel or colon with air-fluid levels contraindicates attempts at proximal softening or washout using oral solutions. Test of the abdomen may reveal a malleable, tubular construction indicating a stool-filled rectosigmoid. Signs of perforation (tenderness or peritoneal signs) are generally absent.four Although virtually impactions occur in the rectal vault, the absence of palpable stool does not rule out a fecal impaction.6
Abdominal radiograph showing fecal impaction.
TREATMENT
Treatment is aimed at relieving the major complaint and correcting the underlying pathophysiology to prevent recurrence. Fecal impaction in the rectum oftentimes requires digital fragmentation and mechanical removal.i
Transmission Disimpaction
If hardened stool is palpable in the rectum, it may require manual fragmentation or disimpaction. A lubricated, gloved alphabetize finger is inserted into the rectum and the hardened stool is gently broken up using a scissoring motion. The finger is and then moved in a circular manner, bent slightly and removed, extracting stool with it. This maneuver is repeated until the rectum is cleared of hardened stool. Manual disimpaction may be aided past the use of an anal retractor (i.east., Hill-Ferguson retractor).iv
Distal Softening or Washout
Softening of hardened stool and stimulation of evacuation with enemas and suppositories is oftentimes helpful. A diversity of enema solutions are available, and each has characteristics that may exist useful in selected patients. Nigh enema solutions contain h2o and an osmotic amanuensis. One such combination contains water, docusate sodium syrup (Colace; Shire Us Inc, Florence, KY), and sorbitol. Docusate sodium is a surface-active amanuensis that helps soften the stool every bit it mixes with water.4 Sorbitol is a sugar alcohol that acts as an osmotic amanuensis. Rectally administered solutions mechanically soften the impacted stool and the boosted volume gently stimulates the rectum to evacuate.
During enema assistants, the patient is placed in the Sims' position with a plastic pocketbook under the hips. The enema is given using a 24 French rubber catheter that is passed through a rubber brawl (i.e., tennis ball, Fig. two). The ball allows the administrator to maintain a seal against the patient's anus. Balloon-tipped catheters are not used as they may impairment the distal rectum and generally do non maintain an adequate seal.4 The pressure and volume of enema administration must exist advisable. Enema pressure is controlled by the pinnacle of the solution reservoir. Limiting the reservoir height to three feet above the anus maintains an acceptable pressure limit. The volume and charge per unit of fluid administration are guided by the size of the patient's rectum and the degree of fullness symptoms. Administration of smaller volumes (1–ii 50) may be more beneficial than a unmarried large-volume enema. A slower rate of enema administration produces less patient discomfort, aids in mixing of solution, and allows instillation of a larger volume. The patient'southward sensation of fullness is a helpful guide during enema instillation. Volumes or rates that produce discomfort in the patient are avoided.four
Catheter suitable for enema assistants.
When assistants is complete, a few minutes are immune for the solution to mix with and soften the stool. Gentle massaging of the lower abdomen often aids in mixing the combination. The patient and then voluntarily evacuates the enema-stool mixture. Additional, gentle abdominal manipulation oft helps in evacuation. Convalescent patients can evacuate more efficiently by using a commode. This process is repeated until the symptoms are relieved and returns are clear.four
Proximal Softening or Washout
Oral lavage with polyethylene glycol solutions containing electrolytes (GoLYTELY or NuLytely, Braintree Laboratories, Braintree, MA; CoLyte, Schwartz Pharma, Milwaukee, WI) may be used to soften or wash out proximal stool.3 Such solutions without electrolytes (MiraLax, Braintree Laboratories, Braintree, MA) have too been used. This technique is contraindicated when a bowel obstruction exists.
The volume and rate of oral lavage are dependent on the patient'southward size. To treat childhood fecal impaction, Youssef and coworkers recommend 1 to 1.5 g/kg/day of polyethylene glycol solution (PEG 3350, MiraLax).vii For adults, oral regimens vary from 1 to ii L of polyethylene glycol with electrolytes or 17 g of PEG 3350 in 4 to 8 oz of h2o every 15 minutes until the patient begins passing stool or viii glasses have been consumed.10 Development of nausea, vomiting, or meaning abdominal discomfort prompts cessation of fluid intake.
Other osmotic laxatives such every bit oral sodium phosphate (Fleet® Phopho-Soda, C.B. Fleet, Lynchburg, VA) take also been used for proximal lavage. Xv milliliters of sodium phosphate orally with iv oz of clear liquids every four to 8 hours is a common regimen. Phosphate-containing solutions are contraindicated in patients with renal insufficiency and congestive centre failure.
SPECIAL SITUATIONS
Barium Impaction
Following barium radiographic studies (barium enema and upper gastrointestinal studies), the barium may be retained in the colon and become impacted with stool. Barium is not water soluble and becomes inspissated in the colon when the water is absorbed. Anatomic or functional abnormalities of the lower gastrointestinal tract can predispose to such impactions.
Patients undergoing barium studies should ingest boosted fluids following the test to prevent a barium impaction. Employ of a laxative such as milk of magnesia may too be beneficial. Medical advice should exist sought if no bowel movement occurs within 48 hours of the radiologic exam or symptoms of fecal impaction develop.
The presence of a barium impaction is readily apparent on patently films. An anteroposterior or lateral intestinal film reveals the amount and location of the retained barium. The absence of signs of perforation (contrast extravasation or free air) or bowel obstacle should besides be confirmed. Perforation generally requires operative management. In the absence of perforation or obstruction, removal of barium impaction should proceed as outlined before.
Anorectal Surgery
Fecal impaction following anorectal surgery is a rare but serious complexity. Buls and Goldberg reported a 0.four% incidence of impaction after operative hemorrhoidectomy.eleven Fecal impaction occurring afterwards anorectal surgery is multifactorial. Opiates used for hurting relief in the postoperative period have significant constipating action. Anal canal edema and sphincter spasm as well chemical compound the problem. Patients' fear of hurting associated with bowel movements may lead to deference of bowel movements, resulting in hardened, impacted stool. The presence of a significant impaction is suggested by a history of infrequent bowel movements and perineal pressure and pain.
Mild impactions are relieved with the gentle administration of a retention enema. Posthemorrhoidectomy patients with significant impactions often require disimpaction under anesthesia. An anal block can be administered in the operating room or the endoscopy suite in combination with conscious sedation. Xylocaine 0.5% or ane% with or without epinephrine is injected effectually the anus and into the anal sphincter complex. A pocket-size anal retractor is helpful in guiding needle placement. The fecal impaction may be gently digitally removed one time the local anesthetic takes upshot.4
After removal of the impaction, the patient should be placed on additional stool softeners and laxatives and advised on the importance of regular bowel movements.
Mail-Treatment Evaluation and Prevention
When the impaction has been adequately treated, possible etiologies are explored. A total colonic evaluation (colonoscopy or barium enema) should be performed to reveal anatomic abnormalities (stricture or malignancy). Endocrine and metabolic screening, including thyroid function tests, is likewise indicated.six
In the absenteeism of an anatomic abnormality, a bulking amanuensis (psyllium, methylcellulose) or an osmotic agent such as polyethylene glycol (MiraLax®) is administered to produce soft regular bowel movements. Other take chances factors such as depression, immobility, lack of practice, and inadequate admission to toilet facilities should also be corrected.2
SUMMARY
In summary, fecal impaction is a common gastrointestinal trouble. Prompt identification and treatment minimize patients' discomfort and potential morbidity. Treatment options include digital disimpaction and proximal or distal washout. Following treatment, possible etiologies should be institute and preventive therapy instituted to avert recurrence.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780143/
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