The articles by Knobel et al.1 and Yuan et al.2 in this issue of the Journal remind us that fecal impaction is not always a benign condition. If unrecognized and, therefore, untreated a fecal impaction may not only cause considerable suffering to the patient but may lead to significant morbidity and mortality.
Constipation and fecal impaction are common problems in the elderly institutionalized patient. In this day of increasing life expectancy and polypharmacy we can anticipate that we shall continue to encounter this problem.
Factors contributing to constipation and fecal impaction are numerous and include low fiber diets, dehydration, immobility, anorectal disease, obstructing lesions of the colon, neuromuscular diseases and medications including narcotics, anticholinergics, and many antipsychotics and antihypertensives.3
This diagnosis is often delayed because elderly institutionalized patients may not be cognizant of their symptoms and may not be able to express themselves adequately. The first indication of the impaction may be diarrhea and rectal incontinence that the unsuspecting physician may treat with an antidiarrheal agent, thereby compounding the problem. The physician must have a high level of suspicion and must exclude the possibility of an impaction by a rectal exam before instituting antidiarrheal therapy in the patient at risk who has new onset diarrhea. In patients with a more proximal impaction, the diagnosis may only be established by sigmoidoscopy or by radiological studies.
The complications of a fecal impaction are, fortunately, not common but include urinary tract obstruction, perforation of the colon, dehydration, electrolyte imbalance, renal insufficiency, fecal incontinence, decubitus ulcers, stercoral ulcers, and rectal bleeding. Because fecal impactions tend to occur in the elderly and chronically ill patient, these complications can prove fatal.
The treatment of a fecal impaction usually requires the digital fragmentation and extraction of the stool. Lubricating enemas and suppositories may be helpful. Sedation or anesthesia, local or general, may occasionally be needed. Surgical removal of the impaction may be necessary in refractory cases. Potent laxatives should be avoided because they may increase pain and may contribute to perforation if there is a significant obstruction.
Obviously, prevention is the best strategy. In the institutionalized patient, the daily recording of bowel movements and the liberal use of stool softeners should be encouraged. Many institutions have a protocol whereby patients are given laxatives or enemas if there has not been a bowel movement in a prescribed number of days. If a patient is placed on a constipating medication, they should be alerted to this potential side effect. This is one problem that the physician should recognize and treat before complications do occur.
James Tracey, M.D.
Senior Attending; Norwalk Hospital; Yale University School of Medicine; Norwalk, CT
1. Knobel B, Rosman P, Gewurtz G. Bilateral hydronephrosis due to fecaloma in an elderly woman. J Clin Gastroenterol
2. Yuan R, Zhao GG, Papez S, Cleary J, Heliotis A. Urethral obstruction and bilateral ureteral hydronephroses secondary to fecal impaction. J Clin Gastroenterol
3. Wrenn K. Fecal impaction. N Engl J Med