What is the treatment for severe fecal impaction?

From the Guidelines

Severe fecal loading should be treated with disimpaction, usually through digital fragmentation and extraction of the stool, followed by the implementation of a maintenance bowel regimen to prevent recurrence, as recommended by the ESMO clinical practice guidelines 1.

Treatment Approach

The treatment of severe fecal loading typically involves a combination of oral laxatives, suppositories, and enemas.

• Oral laxatives such as polyethylene glycol (Miralax, 17g in 8oz water once or twice daily), lactulose (15-30ml daily), or magnesium citrate (one 10oz bottle) can be used to soften the stool and stimulate bowel movements.
• Suppositories (bisacodyl 10mg) or enemas (Fleet phosphate or mineral oil enemas) may be necessary for more severe cases, as they can help to increase water content and stimulate peristalsis to aid in expulsion 1.
• Manual disimpaction may be required in extreme cases, where a healthcare provider physically removes the impacted stool using a lubricated, gloved finger, and should only be performed by medical professionals.

Maintenance Regimen

For ongoing management after the initial disimpaction, a maintenance regimen of:

• Stool softeners (docusate sodium 100mg twice daily)
• Increased fluid intake (at least 2 liters daily)
• Dietary fiber (25-30g daily)
• Regular physical activity is recommended 1. This approach can help to prevent recurrence of severe fecal loading and promote overall bowel health.

Important Considerations

It is essential to note that severe fecal loading can lead to complications such as bowel obstruction, and symptoms such as severe abdominal pain, vomiting, or inability to pass gas require immediate medical attention.

• Enemas are contraindicated for patients with certain conditions, including neutropaenia or thrombocytopaenia, paralytic ileus or intestinal obstruction, recent colorectal or gynaecological surgery, recent anal or rectal trauma, severe colitis, inflammation or infection of the abdomen, toxic megacolon, undiagnosed abdominal pain or recent radiotherapy to the pelvic area 1.

From the FDA Drug Label

USE • relieves occasional constipation (irregularity) • generally produces a bowel movement in 1 to 3 days The answer to treating severe fecal loading is not directly addressed by the information provided in the drug label for polyethylene glycol (PO) 2.

• Severe fecal loading may require more urgent or aggressive treatment than occasional constipation.
• The drug label does not provide guidance on treating severe fecal loading. The FDA drug label does not answer the question.

From the Research

Treatment Options for Severe Fecal Loading

• Manual disimpaction or fragmentation can be used to address fecal impaction of the rectum 3
• Distal and/or proximal softening or washout procedures such as enemas and suppositories can also be used 3
• Oral or nasogastric tube placement for the administration of polyethylene glycol solutions containing electrolytes is another option 3, 4
• In severe cases, surgical intervention may be necessary 3

Medications for Treatment and Maintenance

• Polyethylene glycol 3350 plus electrolytes (PEG + E) can be used as oral monotherapy for the treatment of fecal impaction in children 4
• PEG + E is safe and highly effective in the management of childhood constipation and can be used for disimpaction without invasive interventions 4
• Lactulose can be used as maintenance therapy, but PEG + E is significantly more effective in preventing the recurrence of fecal impaction 4

Post-Treatment Evaluation and Prevention

• Post-treatment evaluation should include a colonic evaluation by flexible sigmoidoscopy, a colonoscopy, or a barium enema after the fecal impaction resolves 3
• An evaluation of causes and creation of a preventive therapy plan should be conducted following treatment 3