From the Guidelines
The treatment for a high fecal impaction typically involves manual disimpaction followed by medication therapy, with the goal of mechanically removing the obstruction and addressing the underlying constipation that led to the impaction.
Treatment Approach
The approach to treating high fecal impaction should prioritize the patient's comfort and safety, aiming to relieve the obstruction while minimizing the risk of complications.
- Manual disimpaction is often the first step, where a healthcare provider performs a digital rectal examination to break up and remove the impacted stool if it's accessible.
- For high impactions that cannot be reached manually, an enema such as sodium phosphate (Fleet) or mineral oil may be necessary to soften the stool and stimulate evacuation.
- Oral medications are also crucial, including osmotic laxatives like polyethylene glycol (Miralax, 17g in 8oz water daily), stimulant laxatives such as bisacodyl (5-10mg daily), or stool softeners like docusate sodium (100mg twice daily) 1.
Importance of Hydration and Maintenance
Adequate hydration is essential during treatment, with patients needing to drink 2-3 liters of water daily to help soften the stool.
- After the impaction is resolved, a maintenance regimen including fiber supplementation (20-30g daily), continued hydration, and possibly scheduled laxative use may be necessary to prevent recurrence.
- The use of peripherally acting μ-opioid receptor antagonists like methylnaltrexone may be considered for patients experiencing constipation that has not responded to standard laxative therapy, as recommended by the NCCN Palliative Care Panel 1.
Considerations for Specific Patient Groups
For patients with opioid-induced constipation, medications such as methylnaltrexone can provide effective relief while maintaining pain management 1.
- In cases where gastroparesis is suspected, the addition of a prokinetic agent like metoclopramide may be considered to aid in bowel motility.
- The treatment plan should be tailored to the individual patient's needs, taking into account their overall health status, the presence of any underlying conditions, and their response to initial treatments.
From the Research
Treatment Options for High Fecal Impaction
- 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 are common treatment options for fecal impaction of the rectum 2.
- 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 3.
- Polyethylene glycol 3350 plus electrolytes (PEG + E) is safe and highly effective in the management of childhood constipation, allowing a single orally administered laxative to be used for disimpaction without recourse to invasive interventions 4.
- Lactulose may be a good alternative to PEG in the treatment of faecal impaction in constipated children, as it is cheap and widely available, and has been shown to be effective and safe in disimpaction and maintenance therapy 5.
Severe Cases and Post-Treatment Evaluation
- In severe cases of fecal impaction, surgical intervention may be necessary 2.
- Post-treatment evaluation should include a colonic evaluation by flexible sigmoidoscopy, a colonoscopy, or a barium enema after the fecal impaction resolves, and an evaluation of causes and creation of a preventive therapy plan 2.
Note: The study 6 is not relevant to the treatment of high fecal impaction.