LecturePatient will present as → an elderly bed-bound patient with impaired mental function and poor fluid/fiber intake who complains of incontinence of liquid stool. He also reports rectal pressure and lower abdominal pain. The pain is cramping in quality and the patient’s abdomen is “bloated.” Digital rectal examination reveals a large amount of stool in the rectum.
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Fecal impaction is a large mass of hard, retained stool
- It generally occurs in the rectum but also may occur higher in the colon
- Complications include UTI, perforation of the colon, fecalith formation leading to appendicitis
Rock hard stool in the rectal vault on examination is diagnostic of distal impaction
- Abdominal plain film or CT will be confirmatory
- Elderly are at greater risk for developing a chronic constipation
- Follow up colonoscopy to r/o colon CA
Manual disimpaction digitally, followed by saline or tepid water enema for distal impaction
- More proximal impaction can be broken up by sigmoidoscopic water irrigation and suction
- Ensure patient has sufficient fiber intake and hydration
Question 1 |
An elderly patient is brought in to the emergency department (ED) complaining of incontinence of liquid “like tea water” stool. He is complaining of rectal pressure and lower abdominal pain. The pain is cramping in quality and the patient's abdomen is “bloated.” Digital rectal exam reveals hard stool in the rectum. Which of the following should be selected as the initial treatment for this patient?
passing a nasogastric tube Hint: A nasogastric tube would not be used for an obstruction in the distal colon/rectum. | |
milk of magnesia Hint: Mechanical bowel obstruction in the rectum does not usually respond to oral laxatives. | |
opiate analgesics for pain Hint: One would avoid opiates in fecal impactions and other constipation problems because they tend to be more constipating. | |
oral sodium phosphate Hint: Mechanical bowel obstruction in the rectum does not usually respond to oral laxatives. | |
manual disimpaction |
Question 1 Explanation:
Mechanical bowel obstruction in the rectum does not usually respond to oral laxatives. A nasogastric tube would not be used for an obstruction in the distal colon/rectum. One would avoid opiates in fecal impactions and other constipation problems because they tend to be more constipating. This patient needs to be disimpacted. Oral agents are unlikely to be effective against the fecal impaction and may cause complications.
There is 1 question to complete.
References: Merck Manual · UpToDate
