What is the best course of action for an older adult patient with a recent spinal compression fracture, presenting with severe constipation, nausea, and back pain, who has not had a bowel movement in 11 days despite receiving an enema and having abundant stool in the large intestine shown on a computed tomography (CT) abdomen scan?

Immediate Management of Severe Fecal Impaction in an Elderly Patient with Spinal Compression Fracture

This patient requires manual disimpaction immediately, followed by aggressive oral laxative therapy with polyethylene glycol (PEG) and bisacodyl, as the failed enema indicates severe fecal impaction that will not resolve with rectal measures alone. 1

Urgent Intervention Required

Manual disimpaction must be performed first - the ESMO guidelines explicitly state that in the absence of suspected perforation or bleeding, best practice involves disimpaction through digital fragmentation and extraction of stool. 1 The fact that an enema failed and CT shows abundant stool throughout the colon indicates this is severe impaction requiring mechanical intervention, not just additional laxatives.

Step 1: Manual Disimpaction

• Perform digital rectal examination and manual disimpaction with fragmentation and extraction of impacted stool 1
• This should be done urgently given 11 days without bowel movement, severe discomfort, and nausea 1
• If unable to perform in office, the patient needs hospital readmission for this procedure 1

Step 2: Aggressive Oral Laxative Regimen

Immediately start PEG at escalated dosing:

• Begin PEG 17g twice daily (34g total per day) rather than standard once-daily dosing 2
• PEG is the preferred agent for elderly patients due to excellent safety profile and lack of electrolyte disturbances 1, 2

Add stimulant laxative concurrently:

• Start bisacodyl 10-15 mg daily in addition to PEG 2
• The American Gastroenterological Association recommends adding bisacodyl when PEG alone is insufficient 2
• Stimulant laxatives are appropriate in elderly patients, though monitor for cramping 1

Step 3: Additional Rectal Measures

Use isotonic saline enemas, NOT sodium phosphate:

• Isotonic saline enemas are preferable in older adults to avoid electrolyte disturbances from sodium phosphate enemas 1
• Can repeat daily until bowel movements resume 1
• Glycerin suppositories can be added as adjunct 1

Critical Safety Considerations

Avoid these interventions in this patient:

• NO bulk-forming agents (psyllium, methylcellulose) - these are contraindicated in non-ambulatory elderly patients with low fluid intake due to risk of mechanical obstruction 1, 2
• NO magnesium-based laxatives - avoid magnesium hydroxide due to risk of hypermagnesemia in elderly patients 1, 2
• NO liquid paraffin - contraindicated if patient has decreased mobility due to aspiration risk 1

Monitor for complications:

• Watch for signs of bowel obstruction or perforation (worsening abdominal pain, distension, fever) 3, 4
• The nausea and pain may be related to both the impaction and the spinal fracture itself 5
• Assess for opioid use contributing to constipation - if on opioids for fracture pain, this is likely opioid-induced constipation requiring more aggressive management 1

Pain Management Considerations

The spinal compression fracture is complicating this scenario:

• Her immobility from the fracture is contributing to constipation 1
• If she's on opioid analgesics for fracture pain, these are likely the primary cause of severe constipation 1
• Consider non-opioid pain management strategies to reduce constipating effects while maintaining adequate analgesia 1

Follow-up Protocol

Reassess within 24-48 hours:

• Goal is at least one non-forced bowel movement within 1-2 days after disimpaction 2, 6
• If no improvement after 3-4 days on this regimen, consider hospital admission for more aggressive management 2
• Continue maintenance bowel regimen (PEG 17g daily minimum) indefinitely to prevent recurrence 1

Ensure supportive measures:

• Maximize fluid intake if not contraindicated 1
• Ensure toilet access despite mobility limitations from fracture 1, 2
• Educate to attempt defecation 30 minutes after meals, twice daily, straining no more than 5 minutes 1, 2

Key Pitfall to Avoid

The most common error here would be simply prescribing more oral laxatives without manual disimpaction. After 11 days and a failed enema with abundant stool on CT, oral agents alone will not resolve this impaction - mechanical removal is required first. 1 The combination of spinal fracture immobility, likely opioid use, and 11 days of impaction creates a perfect storm requiring immediate aggressive intervention to prevent complications like stercoral ulceration or perforation. 7