Fecal impaction
Encyclopedia
A fecal impaction is a solid, immobile bulk of human feces
that can develop in the rectum
as a result of chronic constipation
.
and paradoxical or overflow diarrhea (encopresis
) as liquid stool passes around the obstruction. Complications may include necrosis
and ulcer
s of the rectal tissue. Abdominal pain and bloating could also be present depending on the severity of the condition. Loss of appetite can also occur.
results in dry, hard stool
s that in the case of fecal impaction become compacted into a large, hard mass of stool that can not be expelled from the rectum
. Various methods of treatment attempt to remove the impaction by softening the stool, lubricating the stool, or breaking it into pieces small enough for removal. Enema
s and osmotic laxatives can be used to soften the stool by increasing the water content until it is soft enough to be expelled. Osmotic laxatives such as magnesium citrate
require 4–8 hours for onset of action, and even then they may not be sufficient to expel the stool. Osmotic laxatives can cause cramping and even severe pain as the patient's attempts to evacuate the contents of the rectum are blocked by the fecal mass. Polyethylene glycol
(PEG 3500) may be used to increase the water content of the stool without cramping; however since it may take 24 to 48 hours for it to take effect, it is not well suited to cases where the impaction needs to be removed immediately due to risk of complications or severe pain. Enema
s (such as hyperosmotic saline) and suppositories (such as glycerine suppositories) work by increasing water content and stimulating peristalsis
to aid in expulsion, and both work much more quickly than oral laxatives. Since enemas work in 2–15 minutes they do not allow sufficient time for a large fecal mass to soften, and even if the enema is successful at dislodging the impacted stool, it may remain too large to be expelled through the anal canal. Mineral oil
enemas can assist by lubricating the stool for easier passage. In cases where enemas fail to remove the impaction polyethylene glycol can be used to attempt to soften the mass over 24–48 hours, or if immediate removal of the mass is needed manual disimpaction may be used. Manual disimpaction may be performed by lubricating the anus
and using one digit with a scoop-like motion to break up the fecal mass. Most often manual disimpaction is performed without general anesthesia although sedation
may be used. In more involved procedures general anesthesia may be used, although the use of general anesthesia increases the risk of damage to the anal sphincter. If all other treatments fail surgery
may be necessary.
Individuals who have had one fecal impaction are at high risk of future impactions. Therefore, preventative treatment should be instituted in patients following the removal of the mass. Increasing dietary fiber
, increasing fluid intake, daily exercise, and regular attempts to defecate every morning after eating should be promoted in all patients. Often underlying medical conditions cause fecal impactions, and these conditions should be treated to reduce the risk of future impactions. Many types of medication
s (most notably opioid
pain medications, such as codeine) reduce motility of the colon, increasing the likelihood of fecal impactions. If possible, alternate medications should be prescribed that avoid the side effect of constipation
. Given that all opioids can cause constipation, it is recommended that any patient placed on opioid pain medications should be given medications to prevent constipation before it occurs. Daily medications can also be used to promote normal motility of the colon and soften stools. Daily use of laxative
s should be avoided by most individuals as it can cause the loss of normal colon motility. However for patients with chronic complications, daily medication under the direction of a physician may be needed. Polyethylene glycol 3350 can be taken daily to soften the stools without the significant risk of adverse effects that are common with other laxatives. In particular, stimulant laxatives should not be used frequently since they can cause dependence in which an individual loses normal colon function and is unable to defecate without taking a laxative. Frequent use of osmotic laxatives should be avoided as well as they can cause electrolyte
imbalances.
), and not drinking enough water. Medications such as narcotic pain relievers (codeine, oxycodone, hydrocodone, tramadol, etc) and certain sedatives that reduce intestinal movement may cause fecal matter to become too large, hard and/or dry to expel.
Manual removal of a fecal impaction is often required with obese patients in traction, after a barium enema
, and in poorly hydrated older adults.
and daily exercise.
Human feces
Human feces , also known as a stool, is the waste product of the human digestive system including bacteria. It varies significantly in appearance, according to the state of the digestive system, diet and general health....
that can develop in the rectum
Rectum
The rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long...
as a result of chronic constipation
Constipation
Constipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...
.
Symptoms
Symptoms include chronic constipation. There can be fecal incontinenceFecal incontinence
Fecal incontinence is the loss of regular control of the bowels. Involuntary excretion and leaking are common occurrences for those affected. Subjects relating to defecation are often socially unacceptable, thus those affected may be beset by feelings of shame and humiliation...
and paradoxical or overflow diarrhea (encopresis
Encopresis
Encopresis is involuntary fecal soiling in adults and children who have usually already been toilet trained. Persons with encopresis often leak stool into their undergarments.-Prevalence:The estimated prevalence of encopresis in four-year-olds is between one and three percent...
) as liquid stool passes around the obstruction. Complications may include necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
and ulcer
Peptic ulcer
A peptic ulcer, also known as PUD or peptic ulcer disease, is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions equal to or greater than 0.5 cm...
s of the rectal tissue. Abdominal pain and bloating could also be present depending on the severity of the condition. Loss of appetite can also occur.
Treatment
The treatment of fecal impaction requires both the remedy of the impaction and treatment to prevent future recurrences. Decreased motility of the colonColon (anatomy)
The colon is the last part of the digestive system in most vertebrates; it extracts water and salt from solid wastes before they are eliminated from the body, and is the site in which flora-aided fermentation of unabsorbed material occurs. Unlike the small intestine, the colon does not play a...
results in dry, hard stool
Human feces
Human feces , also known as a stool, is the waste product of the human digestive system including bacteria. It varies significantly in appearance, according to the state of the digestive system, diet and general health....
s that in the case of fecal impaction become compacted into a large, hard mass of stool that can not be expelled from the rectum
Rectum
The rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long...
. Various methods of treatment attempt to remove the impaction by softening the stool, lubricating the stool, or breaking it into pieces small enough for removal. Enema
Enema
An enema is the procedure of introducing liquids into the rectum and colon via the anus. The increasing volume of the liquid causes rapid expansion of the lower intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful peristalsis, a feeling of extreme urgency and...
s and osmotic laxatives can be used to soften the stool by increasing the water content until it is soft enough to be expelled. Osmotic laxatives such as magnesium citrate
Magnesium citrate
Magnesium citrate, a magnesium salt of citric acid, is a chemical agent used medicinally as a saline laxative and to completely empty the bowel prior to a major surgery or colonoscopy. It is available without a prescription, both as a generic brand or under the brand name Citromag or Citroma. It is...
require 4–8 hours for onset of action, and even then they may not be sufficient to expel the stool. Osmotic laxatives can cause cramping and even severe pain as the patient's attempts to evacuate the contents of the rectum are blocked by the fecal mass. Polyethylene glycol
Polyethylene glycol
Polyethylene glycol is a polyether compound with many applications from industrial manufacturing to medicine. It has also been known as polyethylene oxide or polyoxyethylene , depending on its molecular weight, and under the tradename Carbowax.-Available forms:PEG, PEO, or POE refers to an...
(PEG 3500) may be used to increase the water content of the stool without cramping; however since it may take 24 to 48 hours for it to take effect, it is not well suited to cases where the impaction needs to be removed immediately due to risk of complications or severe pain. Enema
Enema
An enema is the procedure of introducing liquids into the rectum and colon via the anus. The increasing volume of the liquid causes rapid expansion of the lower intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful peristalsis, a feeling of extreme urgency and...
s (such as hyperosmotic saline) and suppositories (such as glycerine suppositories) work by increasing water content and stimulating peristalsis
Peristalsis
Peristalsis is a radially symmetrical contraction and relaxation of muscles which propagates in a wave down the muscular tube, in an anterograde fashion. In humans, peristalsis is found in the contraction of smooth muscles to propel contents through the digestive tract. Earthworms use a similar...
to aid in expulsion, and both work much more quickly than oral laxatives. Since enemas work in 2–15 minutes they do not allow sufficient time for a large fecal mass to soften, and even if the enema is successful at dislodging the impacted stool, it may remain too large to be expelled through the anal canal. Mineral oil
Mineral oil
A mineral oil is any of various colorless, odorless, light mixtures of alkanes in the C15 to C40 range from a non-vegetable source, particularly a distillate of petroleum....
enemas can assist by lubricating the stool for easier passage. In cases where enemas fail to remove the impaction polyethylene glycol can be used to attempt to soften the mass over 24–48 hours, or if immediate removal of the mass is needed manual disimpaction may be used. Manual disimpaction may be performed by lubricating the anus
Anus
The anus is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, unwanted semi-solid matter produced during digestion, which, depending on the type of animal, may be one or more of: matter which the animal cannot digest,...
and using one digit with a scoop-like motion to break up the fecal mass. Most often manual disimpaction is performed without general anesthesia although sedation
Sedation
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure...
may be used. In more involved procedures general anesthesia may be used, although the use of general anesthesia increases the risk of damage to the anal sphincter. If all other treatments fail surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
may be necessary.
Individuals who have had one fecal impaction are at high risk of future impactions. Therefore, preventative treatment should be instituted in patients following the removal of the mass. Increasing dietary fiber
Dietary fiber
Dietary fiber, dietary fibre, or sometimes roughage is the indigestible portion of plant foods having two main components:* soluble fiber that is readily fermented in the colon into gases and physiologically active byproducts, and* insoluble fiber that is metabolically inert, absorbing water as it...
, increasing fluid intake, daily exercise, and regular attempts to defecate every morning after eating should be promoted in all patients. Often underlying medical conditions cause fecal impactions, and these conditions should be treated to reduce the risk of future impactions. Many types of medication
Medication
A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
s (most notably opioid
Opioid
An opioid is a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract...
pain medications, such as codeine) reduce motility of the colon, increasing the likelihood of fecal impactions. If possible, alternate medications should be prescribed that avoid the side effect of constipation
Constipation
Constipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...
. Given that all opioids can cause constipation, it is recommended that any patient placed on opioid pain medications should be given medications to prevent constipation before it occurs. Daily medications can also be used to promote normal motility of the colon and soften stools. Daily use of laxative
Laxative
Laxatives are foods, compounds, or drugs taken to induce bowel movements or to loosen the stool, most often taken to treat constipation. Certain stimulant, lubricant, and saline laxatives are used to evacuate the colon for rectal and/or bowel examinations, and may be supplemented by enemas under...
s should be avoided by most individuals as it can cause the loss of normal colon motility. However for patients with chronic complications, daily medication under the direction of a physician may be needed. Polyethylene glycol 3350 can be taken daily to soften the stools without the significant risk of adverse effects that are common with other laxatives. In particular, stimulant laxatives should not be used frequently since they can cause dependence in which an individual loses normal colon function and is unable to defecate without taking a laxative. Frequent use of osmotic laxatives should be avoided as well as they can cause electrolyte
Electrolyte
In chemistry, an electrolyte is any substance containing free ions that make the substance electrically conductive. The most typical electrolyte is an ionic solution, but molten electrolytes and solid electrolytes are also possible....
imbalances.
Causes
There are many possible causes; for example, physical inactivity, not eating enough (particularly of fiberDietary fiber
Dietary fiber, dietary fibre, or sometimes roughage is the indigestible portion of plant foods having two main components:* soluble fiber that is readily fermented in the colon into gases and physiologically active byproducts, and* insoluble fiber that is metabolically inert, absorbing water as it...
), and not drinking enough water. Medications such as narcotic pain relievers (codeine, oxycodone, hydrocodone, tramadol, etc) and certain sedatives that reduce intestinal movement may cause fecal matter to become too large, hard and/or dry to expel.
Manual removal of a fecal impaction is often required with obese patients in traction, after a barium enema
Barium enema
A lower gastrointestinal series, also called a barium enema, is a medical procedure used to examine and diagnose problems with the human colon . X-ray pictures are taken while barium sulfate fills the colon via the rectum.-Procedure:...
, and in poorly hydrated older adults.
Prevention
Reducing opiate-based medication, an adequate intake of liquids(water) and dietary fiberDietary fiber
Dietary fiber, dietary fibre, or sometimes roughage is the indigestible portion of plant foods having two main components:* soluble fiber that is readily fermented in the colon into gases and physiologically active byproducts, and* insoluble fiber that is metabolically inert, absorbing water as it...
and daily exercise.
See also
- Adhesion (medicine)Adhesion (medicine)Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.-Pathophysiology:...
- Bowel obstructionBowel obstructionBowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency...
- ConstipationConstipationConstipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...
- EnemaEnemaAn enema is the procedure of introducing liquids into the rectum and colon via the anus. The increasing volume of the liquid causes rapid expansion of the lower intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful peristalsis, a feeling of extreme urgency and...
- FecalomaFecalomaA fecaloma, also called fecalith, fecolith and coprolith, i.e., a "stone" made of feces, is a hardening of feces into lumps of varying size inside the colon, which may appear whenever chronic obstruction of transit occurs, such as in megacolon and chronic constipation...
- Intestinal pseudoobstructionIntestinal pseudoobstructionIntestinal pseudoobstruction is decreased ability of the intestines to push food through, and often causes dilation of various parts of the bowel. It can be a primary condition or caused by another disease...
- VolvulusVolvulusA volvulus is a bowel obstruction with a loop of bowel whose nose has abnormally twisted on itself.-Types:* Volvulus Neonatorum.* Volvulus Small Intestine.* Volvulus Caecum.* Volvulus Sigmoid Colon .* Gastric volvulus....