What is the treatment for a patient with fecal impaction?

Treatment of Fecal Impaction

The first-line treatment for fecal impaction is manual digital fragmentation and extraction of the stool after administering appropriate analgesia and/or anxiolytic, followed by enema administration and immediate implementation of a maintenance bowel regimen to prevent recurrence. 1, 2

Diagnostic Confirmation Before Treatment

• Perform digital rectal examination to confirm the presence of a large mass of dry, hard stool in the rectum 1, 2
• Be aware that impaction in the proximal rectum or sigmoid colon may not be detectable on digital examination 1, 2
• Rule out complications such as perforation, bleeding, or obstruction before proceeding with manual disimpaction 1, 2

Treatment Algorithm for Distal Impaction

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, 2
• This successfully removes impaction in approximately 80% of cases 3

Step 3: Enema Administration

• Administer an enema to facilitate passage of remaining stool 1, 2
• Options include: glycerin suppository, tap water enema, warm oil retention enema, docusate sodium enema, hypertonic sodium phosphate enema, or bisacodyl enema 1, 2

Step 4: Additional Laxatives if Needed

• Consider adding bisacodyl suppository, polyethylene glycol, lactulose, sorbitol, magnesium hydroxide, or magnesium citrate 1, 2

Treatment for Proximal Impaction

• In the absence of complete bowel obstruction, administer lavage with polyethylene glycol (PEG) solutions containing electrolytes to soften or wash out stool 2
• PEG (17 g/day) offers an efficacious and tolerable solution with a good safety profile, particularly for elderly patients 2
• PEG generally produces a bowel movement in 1 to 3 days 4

Critical Contraindications for Enemas

Do not use enemas in patients with: 1, 2

• 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

Prevention of Recurrence (Essential Step)

Implement a maintenance bowel regimen immediately after disimpaction 1, 2

Medication Management

• Discontinue any non-essential constipating medications 1, 2
• Add and titrate bisacodyl 10-15 mg daily to three times daily with a goal of one non-forced bowel movement every 1-2 days 5, 1, 2
• Preferred maintenance laxatives include osmotic laxatives (PEG, lactulose, magnesium salts) and stimulant laxatives (senna, cascara, bisacodyl, sodium picosulfate) 2
• Avoid bulk laxatives such as psyllium, especially in patients with opioid-induced constipation or limited mobility 2

Lifestyle Modifications

• Increase fluid intake and physical activity when appropriate 5, 1
• Consider dietary fiber only for patients with adequate fluid intake 1
• Optimize toileting by educating patients to attempt defecation at least twice daily, usually 30 minutes after meals 1, 2

Special Considerations for High-Risk Populations

Elderly Patients

• Pay particular attention to assessment of elderly patients who are at higher risk for severe constipation and fecal impaction 2
• Ensure access to toilets, especially for patients with decreased mobility 1, 2
• Provide dietetic support and manage decreased food intake 2

Patients with Gastroparesis

• Consider adding a prokinetic agent, such as metoclopramide, for patients with suspected gastroparesis 5, 1

Opioid-Induced Constipation

• Anticipate and treat prophylactically with a stimulating laxative to increase bowel motility, with stool softeners as indicated 5
• Consider methylnaltrexone 0.15 mg per kilogram of body weight every other day (no more than once per day) for patients experiencing constipation that has not responded to standard laxative therapy 5

When Surgery May Be Necessary

• In severe cases where medical therapies are not effective, surgical intervention may be indicated 3, 6
• Endoscopy may be necessary in severe cases 3