Obstipation unresponsive to usual therapeutic maneuvers
Did the patient’s well-intentioned steps to promote bowel health do just the opposite?
Complications from fecal impaction include bowel obstruction, sigmoid volvulus, and rectal prolapse.2 Stercoral ulceration and perforation due to pressure necrosis from a hard, inspissated fecal mass is an uncommon but life-threatening complication requiring resection of the affected colonic segment.8
What to look for on the CT. When the diagnosis is unclear or signs of complications are present, an abdominal CT is indicated. Concerning CT findings include ulceration, bowel wall enhancement and thickening (FIGURE 2), discontinuity of the bowel wall, presence of fecal material either protruding through the colonic wall or lying free within the intra-abdominal cavity, and extraluminal air.8
FIGURE 2
CT scan shows bowel wall thickening
Treatment begins with a pharmacologic approach
By the time a patient with a fecal impaction gets to your office, it’s likely that he or she will have already tried over-the-counter laxatives, stool softeners, and perhaps an enema.
When such pharmacologic management has failed, you’ll need to perform a manual fragmentation and extraction of the fecal mass. Apply topical 2% lidocaine jelly for analgesia and lubrication, and then gently and progressively dilate the anal sphincter with one and then 2 fingers. A scissoring action will fragment the impaction.3
Once fragmentation and partial expulsion has been achieved, you may want to try a lubricating mineral oil enema, bisacodyl suppository, or rectal lavage. If the impaction extends beyond the reach of the fingers, sigmoidoscopic visualization and lavage are indicated.
Adding water-soluble contrast material (Gastrografin) in 20% to 50% solutions directed by fluoroscopy draws water into the lumen, thus lubricating the fecal mass3,9 and helping it to pass spontaneously.
Our patient’s case resolved with a trip to the OR
Since conservative and comprehensive management to improve our patient’s condition failed, she was taken to the operating room for a proctosigmoidoscopic disimpaction. A beveled metal proctoscope was used to disimpact the distal-most 10 cm and then a rigid sigmoidoscope was used to clear the colon of quinoa-laden fecal material to a total distance of 18 cm. Bowel walls were ecchymotic, yet viable and without laceration. She made an uneventful recovery and was discharged on hospital Day 3.
CORRESPONDENCE George L. Higgins, III, MD, Maine Medical Center, Department of Emergency Medicine, 47 Bramhall Street, Portland, ME 04102; higgig@mmc.org
