From the Guidelines
The treatment for retained stool in the rectal vault due to colitis should prioritize a combination of stool softeners, enemas, and manual disimpaction if necessary, alongside addressing the underlying colitis with anti-inflammatory medications, as this approach is crucial for preventing recurrence and managing the condition effectively. When considering the management of retained stool in the rectal vault due to colitis, it's essential to start with the least invasive methods. Initially, stool softeners such as docusate sodium (100-300 mg daily) or polyethylene glycol (17g in 8oz water daily) can be used to soften the stool, making it easier to pass 1. Phosphate enemas (Fleet enema) or mineral oil enemas can help lubricate and evacuate the impacted stool, facilitating a smoother passage and reducing the risk of further complications 1. For severe impaction, manual disimpaction under appropriate analgesia may be required to safely remove the impacted stool and prevent damage to the rectal mucosa. After clearing the impaction, addressing the underlying colitis is essential, typically with anti-inflammatory medications such as mesalamine (800mg three times daily) for mild to moderate cases, or corticosteroids like prednisone (40-60mg daily with taper) for more severe inflammation, as recommended by guidelines for managing inflammatory bowel disease 1. Maintaining adequate hydration and increasing dietary fiber gradually once the acute episode resolves helps prevent recurrence by promoting regular bowel movements and reducing the risk of constipation. Regular bowel regimens may be needed during colitis flares to prevent future impactions, emphasizing the importance of ongoing management and monitoring of the condition. This comprehensive approach prioritizes the patient's morbidity, mortality, and quality of life by addressing both the immediate issue of retained stool and the underlying condition of colitis, thereby reducing the risk of complications and improving overall outcomes.
From the Research
Treatment for Retained Stool in Rectal Vault due to Colitis
The treatment for retained stool in the rectal vault due to colitis typically involves managing the underlying condition of colitis.
- Aminosalicylates, such as mesalamine, have been shown to be effective in maintaining medically induced remissions of both ulcerative colitis and Crohn's disease 2.
- These medications can be administered orally or rectally, with rectal 5-aminosalicylic acid being useful in maintaining long-term remissions of distal ulcerative colitis 2.
- The efficacy of aminosalicylates is dose-related, with higher doses (up to 4-4.8 g/day) providing increased efficacy for induction of remission, particularly in patients with more moderate disease activity 3.
- Combination therapy with oral and rectal mesalazine may provide additional efficacy for patients with both distal and extensive colitis 3.
Management of Colitis
- Aminosalicylates are considered first-line therapies for the treatment of mildly to moderately active inflammatory bowel disease and for maintenance of remissions after successful induction therapy 4.
- Antimetabolites, such as azathioprine and 6-mercaptopurine, are highly beneficial and relatively safe for long-term steroid-sparing therapy in both ulcerative colitis and Crohn's disease 2.
- Corticosteroids and cyclosporine are better suited to the induction of rapid remissions of acute disease than to the maintenance of long-term remissions 2.
Specific Considerations
- The choice of treatment may depend on the location and severity of the disease, as well as the patient's response to previous treatments 4, 5.
- Topical mesalazine (mesalamine) is the most efficacious approach to distal ulcerative colitis, while orally delivered azo conjugates may have an advantage over pH-released mesalazine as a first-line approach to active disease 5.
- The optimal dosing of oral mesalamine as a maintenance agent, and the dose-response and efficacy of aminosalicylates after steroid- or ciclosporin-induced remissions, are areas that require further study 5.