What is the initial management for a patient with a bedside fecal impaction?

Initial Management of Bedside Fecal Impaction

The first-line treatment for fecal impaction is digital fragmentation of the stool followed by enema administration and implementation of a maintenance bowel regimen to prevent recurrence. 1

Diagnostic Confirmation

• Perform digital rectal examination to confirm the presence of a large mass of dry, hard stool in the rectum 1
• Note that impaction in the proximal rectum or sigmoid colon may not be detectable on digital rectal examination 1
• Rule out complications such as perforation, bleeding, or obstruction before proceeding with manual disimpaction 1, 2
• Consider overflow diarrhea as a possible presentation of fecal impaction, which can be misleading 3, 2

Treatment Algorithm

Step 1: Pre-procedure Preparation

• Administer appropriate analgesia and/or anxiolytic before the procedure to minimize patient discomfort 1, 2
• Position the patient in the left lateral decubitus position for optimal access 1

Step 2: Manual Disimpaction

• Perform digital fragmentation and extraction of the stool using a lubricated, gloved finger 1, 4
• This approach successfully removes impaction in approximately 80% of cases 3

Step 3: Enema Administration

• After manual fragmentation, administer an enema to facilitate passage of remaining stool 1, 2
• Options include:
  • Glycerin suppository with or without mineral oil retention enema 2
  • Tap water enema until clear 2
  • Docusate sodium enema 1
  • Bisacodyl enema 1

Step 4: For Persistent Impaction

• Consider adding other laxatives if needed:
  • Bisacodyl suppository (one rectally daily-BID) 2
  • Polyethylene glycol (1 capful/8 oz water BID) 2, 5
  • Lactulose (30-60 mL BID-QID) 2
  • Sorbitol (30 mL every 2 hours × 3, then PRN) 2
  • Magnesium hydroxide (30-60 mL daily-BID) 2
  • Magnesium citrate (8 oz daily) 2

Step 5: For Proximal Impaction

• For impaction not accessible via digital removal, administer lavage with polyethylene glycol solutions containing electrolytes (GoLYTELY) 1, 5
• This can be administered orally, via nasogastric tube, or via gastrostomy tube at a rate of 100 mL/hour 5

Prevention of Recurrence

• Implement a maintenance bowel regimen immediately after disimpaction 1, 4
• Discontinue any non-essential constipating medications 2
• Increase fluid intake and physical activity when appropriate 2
• Consider dietary fiber for patients with adequate fluid intake 2
• Add and titrate bisacodyl 10-15 mg daily-TID with a goal of 1 non-forced bowel movement every 1-2 days 2
• For opioid-induced constipation, consider methylnaltrexone 0.15 mg/kg subcutaneously every other day (no more than once daily) 2

Special Considerations

• For elderly patients, who are at higher risk for severe constipation and fecal impaction, ensure access to toilets and provide dietetic support 1
• Optimize toileting by educating patients to attempt defecation at least twice daily, usually 30 minutes after meals 1
• Consider prokinetic agents (e.g., metoclopramide 10-20 mg PO QID) for patients with gastroparesis 2

Contraindications for Enemas

• Do not use enemas in 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

Follow-up

• After successful disimpaction, conduct an evaluation of causes to prevent recurrence 4, 6
• Consider post-treatment colonic evaluation by flexible sigmoidoscopy, colonoscopy, or barium enema after the fecal impaction resolves to rule out underlying pathology 4