Fecal impaction

Answer 1

Definition

A fecal impaction is a large mass of dry, hard stool that can develop in the rectum due to chronic constipation. This mass may be so hard that it cannot come out of the body. Watery stool from higher in the bowel may move around the mass and leak out, causing soiling or diarrhea.

Alternative Names

Impaction of the bowels

Causes, incidence, and risk factors

Certain people are at greater risk for developing chronic constipation, which can lead to fecal impaction.

Persons at risk for this condition include those who:

• Have limited ability to move such as bedridden patients, or persons with severe disease of the nervous system
• Take certain drugs, including:
  • Anticholinergics, which affect the interaction between certain nerves and muscles
  • Antidiarrhea medications
  • Methadone maintenance treatment for drug addiction
  • Narcotic pain medication

Symptoms

• Abdominal cramping
• Frequent straining with passage of liquid
• Rectal bleeding
• Small, semi-formed stools
• Sudden, watery diarrhea in someone who has chronicconstipation

Signs and tests

The health care provider will examine your stomach area and rectum. The rectal exam will reveal a hard mass of dry stool in the rectum.

If there has been a recent change in your bowel habits, your doctor may recommend a colonoscopy to evaluate for colon or rectal cancer.

Treatment

Treating a fecal impaction involves removing the impacted stool, and taking measures to prevent constipation and future fecal impactions.

MEDICATIONS:

Medications may be used to prevent another fecal impaction. Stool softeners such as docusate may be recommended to help pass soft, formed stools. Bulk fiber laxatives such as Metamucil may be used to add fluid and bulk to the stool.

Glycerin, bisacodyl suppositories, or other gentle laxatives may be used along with a bowel retraining program to establish a pattern of regular bowel movements. Food adjustments may be helpful in those with a limited diet.

SURGERY:

Surgery is rarely needed to treat a fecal impaction. However, if the fecal impaction is not removed, the colon may become overly widened (megacolon) or the bowel can become completely blocked. Both of these conditions require emergency surgery to remove the impaction. Part of the injured bowel might have to be removed as well.

DIET:

Dietary measuressuch as increasing fiber intake from whole-wheat grains, bran, and fresh fruits and vegetables may help add bulk to the stool and promote normal bowel movements. Make special efforts to increase daily fluid intake.

EXERCISE:

Regular exercise helps establish regular bowel movements. People who are confined to a wheelchair or bed should change position often and perform abdominal contraction exercises and leg raises. If possible, do these exercises several times a day. A physical therapist can recommend a program of exercises appropriate for your physical abilities.

OTHER THERAPY:

The treatment of fecal impaction aims to remove the impaction and start a program to maintain normal bowel function. Often a warm mineral oil enema is used to soften and lubricate the fecal impaction. However, enemas alone are usually not enough to remove a large, hardened impaction.

The mass may have to be manually broken up. A health care provider will need to insert one or two fingers into the rectum and slowly break up the mass into smaller pieces so that it can be expelled.

Manual removal of a fecal impaction is usually performed in small steps to reduce the risk of injuring the rectal tissues. A series of suppositories may be given between manual removal attempts, to help clear the bowel.

Expectations (prognosis)

With treatment, the outcome is good.

Complications

• Tear (ulceration) of the rectal tissue
• Tissue death (necrosis) or rectal tissue injury

Calling your health care provider

Tell your health care provider if you are experiencing chronic diarrhea or fecal incontinence after a long period of constipation. Also notify your health care provider if you are experiencing any of the following symptoms:

• Abdominal pain and bloating
• Blood in the stool
• Sudden constipation with abdominal cramps, and an inability to pass gas or stool. In this case, do not take any laxatives. Call your health care provider immediately.
• Very thin, pencil-like stools

Prevention

Prevention of fecal impaction focuses on preventing constipation. Add fiber to the diet to promote normal stools. Also, get enough fluids and exercise to help in the formation of normal stool.

Always respond promptly when you have the urge to go to the bathroom (defecate).

References

Nelson H. Diseases of the rectum and anus. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 148.

Answer 2

Definition

A fecal impaction is a large lump of dry, hard stool that remains stuck in the rectum. It is most often seen in patients with long-term constipation.

Alternative Names

Impaction of the bowels

Causes, incidence, and risk factors

Constipation is when you are not passing stool as often as you normally do. Your stool becomes hard and dry, and it is difficult to pass.

Fecal impaction is often seen in people who have had constipation for a long time and have been using laxatives. Impaction is even more likely when the laxatives are stopped suddenly. The muscles of the intestines forget how to move stool or feces on their own.

Persons at risk for chronic constipation and fecal impaction include those who:

• Do not move around much and spend most of their time in a chair or bed
• Have diseases of the brain or nervous system that damage the nerves that go to the muscles of the intestines

Certain drugs slow the passage of stool through the bowels:

• Anticholinergics, which affect the interaction between nerves and muscles of the bowel
• Medicines used to treat diarrhea, if they are taken too often
• Narcotic pain medication, such as methadone and codeine

Symptoms

Common symptoms include:

• Abdominal cramping and bloating
• Leakage of liquid or sudden episodes of watery diarrhea in someone who has chronicconstipation
• Rectal bleeding
• Small, semi-formed stools
• Straining when trying to pass stools

Other possible symptoms include:

• Bladder pressure or loss of bladder control
• Lower Back pain
• Rapid heartbeat or light-headedness from straining to pass stool

Signs and tests

The health care provider will examine your stomach area and rectum. The rectal exam will reveal a hard mass of stool in the rectum.

If there has been a recent change in your bowel habits, your doctor may recommend a colonoscopy to evaluate for colon or rectal cancer.

Treatment

Treating a fecal impaction involves removing the impacted stool. After that, measures are taken to prevent future fecal impactions.

Often a warm mineral oil enema is used to soften and lubricate the stool. However, enemas alone are usually not enough to remove a large, hardened impaction.

The mass may have to be broken up by hand. This is called manual removal:

• A health care provider will need to insert one or two fingers into the rectum and slowly break up the mass into smaller pieces so that it can come out.
• This process must be done in small steps to avoid causing injury to the rectum.
• Suppositories inserted into the rectum may be given between attempts to help clear the stool.

Surgery is rarely needed to treat a fecal impaction. An overly widened colon (megacolon) or complete blockage of the bowel may require emergency removal of the impaction.

Almost anyone who has had a fecal impaction will need a bowel retraining program. Your doctor and a specially trained nurse or therapist will:

• Take a detailed history of your diet, bowel patterns, laxative use, medications, and medical problems
• Examine you carefully
• Recommend changes in your diet, how to use laxatives and stool softeners, special exercises, lifestyle changes, and other special techniques to retrain your bowel
• Follow you closely to make sure the program works for you

Expectations (prognosis)

With treatment, the outcome is good.

Complications

• Tear (ulceration) of the rectal tissue
• Tissue death (necrosis) or rectal tissue injury

Calling your health care provider

Tell your health care provider if you are experiencing chronic diarrhea or fecal incontinence after a long period of constipation. Also notify your health care provider if you are experiencing any of the following symptoms:

• Abdominal pain and bloating
• Blood in the stool
• Sudden constipation with abdominal cramps, and an inability to pass gas or stool. In this case, do not take any laxatives. Call your health care provider immediately.
• Very thin, pencil-like stools

References

Lembo AJ, Ullman SP. Constipation. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa: Saunders Elsevier;2010:chap 18.

Nelson H. Diseases of the rectum and anus. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 148.

Reviewed By

Review Date: 01/31/2011

David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine; George F Longstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program San Diego, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.