What is the treatment for fecal burden (fecal impaction)?

Treatment of Fecal Impaction

For fecal impaction, the most effective treatment is manual disimpaction (digital fragmentation and extraction of the stool), followed by implementation of a maintenance bowel regimen to prevent recurrence. 1

Initial Management

Distal Fecal Impaction (Confirmed by Digital Rectal Exam)

1. Manual disimpaction:

   • Digital fragmentation and extraction of the stool is the first-line approach for distal fecal impaction 1, 2
   • This procedure successfully removes impaction in approximately 80% of cases 3

2. Rectal measures:

   • Suppositories and enemas are preferred first-line therapy when digital rectal examination identifies a full rectum 1
   • Options include:
     • Glycerin suppositories - soften stool and stimulate rectal motility
     • Bisacodyl suppositories - promote intestinal motility
     • Oil retention enemas - lubricate and soften stool (warm cottonseed, olive oil)
     • Hypertonic sodium phosphate enemas - distend and stimulate rectal motility

Proximal Fecal Impaction

1. Oral laxative therapy:

   • Once distal colon has been partially emptied with disimpaction and enemas, polyethylene glycol (PEG) may be administered orally 1
   • PEG generally produces a bowel movement in 1-3 days 4
   • High-dose PEG regimen: up to eight 13.8g sachets per day (maximum 1L/day) over 2-3 days has shown 89.3% success rate 5

2. Lavage therapy:

   • In the absence of complete bowel obstruction, lavage with PEG solutions containing electrolytes helps soften or wash out stool 1, 2

Important Contraindications and Cautions

• Enemas are contraindicated for patients with:

  • Neutropenia or thrombocytopenia
  • Paralytic ileus or intestinal obstruction
  • Recent colorectal or gynecological surgery
  • Recent anal or rectal trauma
  • Severe colitis, inflammation or infection of the abdomen
  • Toxic megacolon
  • Undiagnosed abdominal pain
  • Recent radiotherapy to the pelvic area 1

• Special considerations for elderly patients:

  • Isotonic saline enemas are preferable in older adults due to potential adverse effects of sodium phosphate enemas 1
  • Arachis oil (peanut-derived) should be avoided in patients with peanut allergies 1

Prevention of Recurrence

After successful disimpaction, implement a maintenance bowel regimen:

1. Non-pharmacological measures:

   • Ensure privacy and comfort for defecation
   • Optimize positioning (small footstool to assist gravity)
   • Increase fluid intake
   • Increase activity and mobility within patient limits
   • Abdominal massage can be efficacious in reducing gastrointestinal symptoms 1

2. Pharmacological prevention:

   • Osmotic laxatives (PEG, lactulose) or stimulant laxatives (senna, bisacodyl) are preferred 1
   • PEG (17g/day) offers an efficacious and tolerable solution especially for elderly patients 1
   • Avoid bulk laxatives in non-ambulatory patients with low fluid intake due to risk of mechanical obstruction 1, 6

3. For opioid-induced constipation:

   • Prescribe concomitant laxatives with opioid analgesics
   • Osmotic or stimulant laxatives are generally preferred
   • Avoid bulk laxatives such as psyllium 1

Monitoring and Follow-up

• Post-treatment evaluation should include colonic evaluation by flexible sigmoidoscopy, colonoscopy, or barium enema after the fecal impaction resolves 2
• Conduct evaluation of underlying causes and create a preventive therapy plan 2, 6
• Monitor for complications of fecal impaction, which may include urinary tract obstruction, perforation of the colon, dehydration, electrolyte imbalance, renal insufficiency, and rectal bleeding 1, 6

Special Considerations for Elderly Patients

• Optimize toileting: educate patients to attempt defecation at least twice a day, usually 30 minutes after meals and to strain no more than 5 minutes 1
• Ensure access to toilets, especially for those with decreased mobility 1
• Provide dietetic support and manage decreased food intake which negatively influences stool volume and consistency 1
• Avoid liquid paraffin for bed-bound patients and those with swallowing disorders due to risk of aspiration pneumonia 1

Remember that early identification and treatment of fecal impaction minimizes complications and improves patient outcomes.