From the Guidelines
The treatment for moderate to large fecal loading should prioritize suppositories and enemas as the 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.
Key Considerations
- The choice of enema type depends on the patient's condition and the rationale for use, with options including normal saline, soap solution, osmotic micro-enema, hypertonic sodium phosphate, docusate sodium, and bisacodyl enemas 1.
- Suppositories containing glycerine, bisacodyl, or CO2-releasing compounds can also be effective for short-term treatment, working as stool softeners and stimulants for rectal motility 1.
- Oral laxatives, such as polyethylene glycol (PEG) solutions, can be used in conjunction with enemas and suppositories to enhance bowel motility and soften the stool mass.
Treatment Approach
- Initial management should focus on disimpaction using a combination of oral laxatives and enemas, with the goal of softening and evacuating the stool from below.
- For more severe impactions, high-volume enemas or manual disimpaction under sedation may be necessary.
- After disimpaction, a maintenance regimen with daily stool softeners, fiber supplements, and adequate hydration is essential to prevent recurrence.
Important Considerations
- Enemas are contraindicated in patients with certain conditions, such as neutropenia, thrombocytopenia, paralytic ileus, or intestinal obstruction, and should be used with caution in patients with renal impairment 1.
- Lifestyle modifications, including increased physical activity, regular toileting habits, and dietary changes with increased fiber intake, should accompany pharmacological treatment for long-term management.
From the Research
Treatment for Moderate to Large Fecal Loading
The treatment for moderate to large fecal loading can be managed with various methods, including:
- The use of polyethylene glycol (PEG) with or without electrolytes, which has been shown to be efficacious in the treatment of functional constipation and fecal impaction 2
- PEG has been compared to other laxatives, such as lactulose, and has been found to be more efficacious in the treatment of functional constipation 2
- The use of PEG in combination with other medications, such as docusate sodium, has been studied, but has not been shown to significantly reduce time to first bowel movement after surgery 3
- Imaging studies, such as X-ray, can be used to assess fecal loading in patients with gastrointestinal symptoms, and can help identify patients who may benefit from treatment for fecal loading 4
Treatment Options
Some treatment options for moderate to large fecal loading include:
- Polyethylene glycol (PEG) with or without electrolytes
- Enemas
- Other laxatives, such as lactulose or docusate sodium
- Combination therapy, such as PEG and docusate sodium
Diagnosis and Assessment
Diagnosis and assessment of fecal loading can be done using:
- Imaging studies, such as X-ray
- Patient reported symptoms, such as constipation, bloating, and accidental bowel leakage
- Physical examination and medical history