What is a fecaloma, specifically in older adults with a history of constipation, neurological disorders, or mobility issues?

What is a Fecaloma?

A fecaloma (also called fecal impaction) is a large, hardened mass of dry stool that becomes lodged in the rectum or colon as a complication of chronic or severe constipation. 1

Definition and Pathophysiology

• A fecaloma represents a firm, organized mass of impacted feces that most commonly develops in the sigmoid colon and rectum, though it can occur anywhere in the large bowel 2, 3
• It results from prolonged stasis of stool that becomes progressively dehydrated and compacted into a solid mass that cannot be evacuated normally 2
• The condition is particularly common in elderly adults, with constipation prevalence ranging from 24% to 50% in this population, and 74% of nursing home residents using daily laxatives 1

High-Risk Populations

Older adults are at substantially elevated risk, particularly those with:

• Neurological disorders affecting the enteric nervous system, as aging causes degenerative changes that impair colonic motility 1
• Mobility limitations that prevent normal toileting access and reduce physical activity needed to stimulate bowel function 4, 5
• Chronic constipation from medications (especially opioids), reduced fluid intake, decreased dietary fiber, or anatomic abnormalities 2, 3
• Institutionalization in nursing homes or assisted living facilities where toileting assistance may be limited 1, 3

Clinical Presentation

• Patients may present with paradoxical diarrhea (overflow incontinence), where watery stool from higher in the bowel leaks around the impacted mass 1
• Abdominal pain, distension, and inability to pass stool or gas are common symptoms 2, 3
• Digital rectal examination (DRE) confirms the diagnosis when the impaction is in the distal rectum, though proximal impactions in the sigmoid colon will not be palpable on DRE 1
• Plain abdominal X-ray can visualize the extent of fecal loading and exclude complete bowel obstruction 1

Serious Complications

Fecaloma can lead to life-threatening complications if not promptly recognized and treated:

• Bowel obstruction that may progress to perforation and peritonitis 2, 3
• Stercoral ulcers (pressure necrosis of the bowel wall from the hard fecal mass) with risk of perforation and bleeding 1, 4
• Urinary tract obstruction from mass effect 1, 4
• Dehydration, electrolyte imbalances, and renal insufficiency 1, 4
• Cardiopulmonary collapse with hemodynamic instability in severe cases 3

Treatment Approach

The ESMO guidelines recommend manual disimpaction as first-line treatment, followed by maintenance therapy to prevent recurrence: 1, 4

• Digital fragmentation and extraction of the stool mass is the initial intervention for distal impactions, but only after excluding perforation or active bleeding 1, 4
• Water or oil retention enemas or suppositories should follow manual extraction to facilitate passage of remaining stool 1, 4
• Polyethylene glycol (PEG) 17 g/day is the preferred maintenance laxative for elderly patients due to its efficacy and excellent safety profile 4, 5
• For proximal impactions without complete obstruction, oral PEG lavage solutions can help soften and wash out the stool 1
• Surgical resection is reserved only for cases complicated by perforation and peritonitis 2, 3

Prevention Strategies

Since recurrence is common, implementing preventive measures is critical:

• Ensure toilet access, especially for patients with decreased mobility 4, 5
• Optimize toileting habits: attempt defecation twice daily, 30 minutes after meals (when gastrocolic reflex is strongest), straining no more than 5 minutes 4, 5
• Increase dietary fiber to 30 g/day and fluid intake to at least 1.5 liters daily 4, 2
• Encourage physical activity within patient limitations, as even minimal bed-to-chair movement stimulates bowel function 4, 5
• Review and discontinue medications that decrease colonic motility when possible 5, 3
• Prescribe prophylactic laxatives (PEG 17 g/day) for high-risk patients, particularly those on chronic opioids 1, 4

Critical Pitfalls to Avoid

• Do not attempt disimpaction if perforation or gastrointestinal bleeding is suspected—these are absolute contraindications 4
• Avoid bulk-forming laxatives in non-ambulatory elderly patients, as they significantly increase obstruction risk without adequate fluid intake 1, 5
• Do not use sodium phosphate enemas in elderly patients due to electrolyte disturbance risk; isotonic saline enemas are safer 1, 4
• Avoid liquid paraffin in bed-bound patients or those with swallowing disorders due to aspiration pneumonia risk 1, 5