PANCE Blueprint GI and Nutrition (9%)

Fecal Impaction (Lecture)

Patient 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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What disease process should you be worried about in an elderly person with recurrent fecal impaction?
Colon Cancer – Get a Colonoscopy

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

  • Abdominal plain film 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 a saline or tepid water enema

  • 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?
A
passing a nasogastric tube
Hint:
A nasogastric tube would not be used for an obstruction in the distal colon/rectum.
B
milk of magnesia
Hint:
Mechanical bowel obstruction in the rectum does not usually respond to oral laxatives.
C
opiate analgesics for pain
Hint:
One would avoid opiates in fecal impactions and other constipation problems because they tend to be more constipating.
D
oral sodium phosphate
Hint:
Mechanical bowel obstruction in the rectum does not usually respond to oral laxatives.
E
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.
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