What is the management approach for fecal stasis?

Management of Fecal Stasis (Fecal Impaction)

The management of fecal stasis requires immediate disimpaction through digital fragmentation and extraction of the stool mass, followed by enemas or suppositories, and then implementation of a maintenance bowel regimen to prevent recurrence. 1

Immediate Management of Fecal Impaction

Initial Assessment and Contraindications

• Perform digital rectal examination (DRE) to confirm the diagnosis of fecal impaction, noting that proximal impactions in the sigmoid colon may not be palpable on DRE 1
• Rule out perforation, bleeding, neutropenia (WBC <0.5 cells/μL), thrombocytopenia, paralytic ileus, intestinal obstruction, recent colorectal/gynecological surgery, recent anal/rectal trauma, severe colitis, toxic megacolon, or recent pelvic radiotherapy before proceeding with enemas or manual disimpaction 1

Distal Fecal Impaction (Palpable on DRE)

• Begin with digital fragmentation and manual extraction of the stool mass 1
• Follow with water or oil retention enemas to facilitate passage through the anal canal 1
• Alternatively, use suppositories (glycerin or bisacodyl) as first-line therapy when DRE identifies a full rectum 1
• Once the distal colon is partially emptied, administer oral polyethylene glycol (PEG) 1

Proximal Fecal Impaction (Not Palpable on DRE)

• In the absence of complete bowel obstruction, use lavage with PEG solutions containing electrolytes to soften or wash out stool 1
• Consider water-soluble contrast media (Gastrografin) to identify the extent of impaction and aid in cleansing and removal 2
• Distal colonic cleansing using rectal lavage with the aid of a sigmoidoscope may be necessary 2

Maintenance Therapy to Prevent Recurrence

First-Line Laxative Therapy

• Prescribe osmotic laxatives as the preferred first-line option: polyethylene glycol (PEG), lactulose, or magnesium salts 1
• Use magnesium and sulfate salts cautiously in renal impairment due to risk of hypermagnesemia 1
• If osmotic laxatives are inadequate, add stimulant laxatives: senna, cascara, bisacodyl, or sodium picosulfate 1
• Avoid bulk laxatives (psyllium, bran) in patients with severe dysmotility or those at risk of impaction 1

Dietary and Lifestyle Modifications

• Increase daily water intake and dietary fiber content to 30 gm/day 3, 2
• Encourage regular physical activity to improve colonic motility 4
• Review and discontinue medications that decrease colonic motility (opioids, anticholinergics, calcium channel blockers) when possible 3, 2

Special Considerations for Opioid-Induced Constipation

• All patients receiving opioid analgesics should be prescribed a concomitant laxative unless contraindicated by pre-existing diarrhea 1
• Osmotic or stimulant laxatives are generally preferred 1
• For unresolved opioid-induced constipation, consider peripheral opioid antagonists such as methylnaltrexone or naloxegol 1
• Combined opioid/naloxone medications can reduce the risk of opioid-induced constipation 1

Monitoring for Complications

Serious Complications Requiring Urgent Intervention

• Monitor for urinary tract obstruction, colonic perforation, dehydration, electrolyte imbalance, renal insufficiency, stercoral ulcers, and rectal bleeding 1, 2
• Surgical resection of the involved colon or rectum is reserved for peritonitis resulting from bowel perforation 3, 2
• Watch for cardiopulmonary collapse with hemodynamic instability in severe cases 2

Common Pitfalls to Avoid

• Do not use enemas in neutropenic patients (WBC <0.5 cells/μL) as this creates a high risk of sepsis 1
• Avoid aggressive manual disimpaction in patients with recent pelvic surgery or radiation therapy due to increased perforation risk 1
• Do not rely solely on oral laxatives for established fecal impaction—disimpaction must be performed first 1
• Recognize that overflow diarrhea (watery stool leaking around impacted stool) is a sign of fecal impaction, not true diarrhea requiring antidiarrheal agents 1
• Recurrence is common (up to 50% in high-risk populations), making maintenance therapy essential 3, 2, 4