What is the management for fecal impaction?

Management of Fecal Impaction

For distal fecal impaction, perform digital fragmentation and extraction after administering analgesia/anxiolytic, followed by water or oil retention enema, then initiate oral polyethylene glycol (PEG) once the distal colon is partially emptied. 1, 2

Diagnostic Confirmation

• Perform digital rectal examination to confirm a large mass of dry, hard stool in the rectum 2, 3
• Note that impaction in the proximal rectum or sigmoid colon may not be palpable on digital examination 2, 3
• Rule out life-threatening complications before proceeding: colonic perforation, stercoral ulceration, rectal bleeding, urinary tract obstruction, and severe dehydration 1

Immediate Treatment Protocol

For Distal (Rectal) Impaction:

Step 1: Pre-procedure preparation

• Administer pain medication and anxiolytic before the procedure to minimize discomfort and reduce risk of vagal stimulation 1, 2, 3
• Position patient in left lateral decubitus position for optimal access 1, 2

Step 2: Manual disimpaction

• Perform digital fragmentation and extraction of stool using a lubricated gloved finger 1, 2, 3
• This is the first-line treatment for distal fecal impaction 1, 3

Step 3: Enema administration

• Follow with water or oil retention enema (warm mineral oil, arachis oil, or glycerin suppository) to facilitate passage of remaining stool 1, 2, 3
• Alternative enema options include docusate sodium enema, bisacodyl enema, or tap water enema 2

Step 4: Oral laxatives

• Once the distal colon is partially emptied, administer oral polyethylene glycol (PEG) to complete evacuation 1

For Proximal (Sigmoid/Descending Colon) Impaction:

• In the absence of complete bowel obstruction, administer lavage with PEG solutions containing electrolytes to soften or wash out stool 3, 4
• Consider adding bisacodyl suppository, lactulose, sorbitol, magnesium hydroxide, or magnesium citrate if needed 2, 3

Critical Contraindications for Enemas

Do not use enemas in patients with: 2, 3

• 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 (Critical Step)

Implement a maintenance bowel regimen immediately after disimpaction to prevent recurrence: 1, 2, 3

First-line laxatives:

• Osmotic laxatives: PEG 17g daily, lactulose, or magnesium salts 1, 3
• Stimulant laxatives: Bisacodyl 10-15 mg daily to three times daily, senna, or sodium picosulfate 1, 2, 3

Goal: One non-forced bowel movement every 1-2 days 1, 2

Avoid bulk laxatives (psyllium) in patients with limited mobility or opioid-induced constipation, as these can worsen impaction 1, 3

Additional preventive measures:

• Discontinue non-essential constipating medications 2, 3
• Increase fluid intake and physical activity when appropriate 2, 3
• Educate patients to attempt defecation at least twice daily, usually 30 minutes after meals 2, 3

High-Risk Populations Requiring Prophylaxis

• Elderly patients with degenerative changes in the enteric nervous system 1
• Opioid users (require prophylactic laxatives) 1
• Immobilized or institutionalized patients with limited toilet access 1
• Cancer patients receiving chemotherapy or radiotherapy 1

When to Consider Surgical Intervention

• Surgical resection is reserved for peritonitis resulting from bowel perforation 5
• Consider surgery for severe cases unresponsive to medical management 4

Common Pitfall to Avoid

Paradoxical overflow diarrhea: When fecal impaction is present, watery stool may leak around the impaction, mimicking diarrhea. 1, 2 Always perform digital rectal examination in patients with new-onset diarrhea to rule out impaction before treating with antidiarrheals, which would worsen the underlying problem.