Should small volume fecal impaction be treated?

From the Guidelines

Small volume fecal loading should be treated with suppositories or small-volume enemas as a preferred first-line therapy, especially when a digital rectal examination (DRE) identifies a full rectum or fecal impaction, as recommended by the ESMO clinical practice guidelines 1.

Treatment Options

• Increasing fluid intake to 6-8 glasses of water daily
• Adding more fiber to the diet (25-30g daily)
• Regular physical activity
• Over-the-counter osmotic laxatives like polyethylene glycol (MiraLAX, 17g in 8oz water daily) or lactulose (15-30ml daily)
• Stimulant laxatives such as bisacodyl (5-10mg orally) or senna (8.6-17.2mg at bedtime)
• Suppositories containing glycerine, bisacodyl, or CO2-releasing compounds
• Small-volume enemas, such as hyperosmotic saline, which increase water content and stimulate peristalsis to aid in expulsion

Considerations

• Treatment should continue until regular bowel movements are established and symptoms resolve
• Small volume fecal loading, if left untreated, can progress to more significant constipation, discomfort, and potentially lead to complications like fecal impaction or bowel obstruction, particularly in elderly or immobile patients
• The goal of treatment is to restore normal bowel function and prevent recurrence through ongoing dietary and lifestyle modifications
• Enemas are contraindicated for patients with 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 Research

Treatment Options for Fecal Impaction

• Manual extraction and proximal or distal washout are treatment options for fecal impaction, as stated in 2.
• Other treatment options include manual disimpaction or fragmentation, the use of distal and/or proximal softening or washout procedures such as enemas and suppositories, and oral or nasogastric tube placement for the administration of polyethylene glycol solutions containing electrolytes, as mentioned in 3.

Efficacy of Polyethylene Glycol

• Polyethylene glycol with or without electrolytes is more efficacious than placebo for the treatment of functional constipation, either in adults or in pediatric patients, with great safety and tolerability, as found in 4.
• Polyethylene glycol is as efficacious as enemas in fecal impaction, avoids the need for hospital admission, and is well tolerated by patients, mainly when administered without electrolytes, as stated in 4.

Over-the-Counter Therapies for Chronic Constipation

• There is good evidence for the use of the osmotic laxative polyethylene glycol (PEG) and the stimulant senna for the treatment of chronic constipation, as reported in 5.
• Moderate evidence supports the use of psyllium, SupraFiber, magnesium salts, stimulants (bisacodyl and sodium picosulfate), fruit-based laxatives (kiwi, mango, prunes, and ficus), and yogurt with galacto-oligosaccharide/prunes/linseed oil, as mentioned in 5.

Diagnosis and Treatment of Faecal Incontinence

• The diagnosis and treatment of faecal incontinence should be guided by the best available evidence, as stated in 6.
• A systematic literature search and quality assessment using the GRADE approach should be performed to formulate recommendations for the diagnosis and management of faecal incontinence, as described in 6.