From the Guidelines
Fecal impaction management requires prompt intervention to prevent serious complications, and treatment should begin with digital disimpaction under appropriate analgesia or sedation, followed by enemas such as mineral oil, sodium phosphate, or milk and molasses enemas, as recommended by the NCCN guidelines 1. The complications of untreated fecal impactions include:
- Bowel obstruction
- Perforation
- Stercoral ulcers
- Rectal bleeding
- Urinary retention
- Autonomic dysreflexia in spinal cord injury patients These complications can be prevented by promptly addressing the impaction and implementing a maintenance bowel regimen. The management of fecal impactions involves:
- Digital disimpaction under appropriate analgesia or sedation
- Enemas such as mineral oil, sodium phosphate, or milk and molasses enemas
- Oral polyethylene glycol (GoLYTELY or MiraLAX) at doses of 1-2 L or 17g in 8oz water 2-4 times daily to help soften and evacuate impacted stool
- Administration of glycerine suppository ± mineral oil retention enema, and performance of manual disimpaction following pre-medication with analgesic ± anxiolytic, as recommended by the NCCN guidelines 1. After resolving the acute impaction, prevention is essential through maintenance bowel regimens including:
- Adequate hydration (2-3L daily)
- Fiber intake (25-30g daily)
- Regular physical activity
- Scheduled toileting Stool softeners like docusate sodium (100mg twice daily) or osmotic laxatives like MiraLAX (17g daily) may be needed long-term for high-risk patients such as the elderly, immobile, or those on constipating medications, as suggested by the NCCN guidelines 1. Addressing underlying causes such as medication side effects, neurological disorders, or anatomical issues is crucial for preventing recurrence, and the NCCN recommends considering the use of a prokinetic agent (e.g., metoclopramide, 10–20 mg PO QID) and methylnaltrexone for opioid-induced constipation, except for post-op ileus and mechanical bowel obstruction, 0.15 mg/kg SC subcut every other day, no more than once a day 1.
From the Research
Complications of Fecal Impactions
- Fecal impaction can lead to severe complications, including bowel obstruction, stercoral ulcer, perforation, peritonitis, and cardiopulmonary collapse with hemodynamic instability 2
- Neglected fecal impaction may lead to a megarectum causing an abdominal compartment syndrome and colorectal obstruction, perforation, or necrosis 3
- Complications can also include aspiration, stercoral ulcers, perforation, and peritonitis 4
- Fecal impaction can cause fecal incontinence, abdominal distention and pain, anorexia, weight loss, intestinal obstruction, and stercoral ulceration with bleeding or colonic perforation 5
Management of Fecal Impactions
- 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 6
- Prompt identification and treatment minimize the risk of complications attributable to fecal impaction, which may include manual fragmentation and extraction of the fecal mass, distal colonic cleansing using enemas and rectal lavage with the aid of a sigmoidoscope 2
- Surgical resection of the involved colon or rectum is reserved for cases of fecal impaction complicated by ulceration and perforation leading to peritonitis 2, 4
- Prevention measures include increasing daily water and fiber intake, limiting medications that decrease colonic motility, using secretagogues or prokinetic agents, and treating underlying anatomic defects 2