Management of Pediatric Fecal Impaction
The most appropriate next step is immediate fecal evacuation (Option C), as the presence of a palpable fecal mass indicates established impaction that must be cleared before any maintenance therapy can be effective. 1
Rationale for Immediate Disimpaction
When a child presents with a palpable abdominal mass consistent with fecal impaction, the priority is to remove the impacted stool before implementing any maintenance regimen. 1, 2 The presence of soiling in this context typically represents overflow incontinence around the impacted mass, not true diarrhea. 3, 4
Digital rectal examination should confirm the diagnosis and identify the location of impaction (distal vs. proximal), though proximal impaction may not be palpable on DRE. 1
Disimpaction Protocol
For Distal (Rectal) Impaction:
- Administer appropriate analgesia and/or anxiolytic before the procedure 1
- Perform digital fragmentation and extraction of the stool 1
- Follow with water or oil retention enema (options include hypertonic sodium phosphate, docusate sodium, warm oil retention, bisacodyl, or glycerol suppositories) 1
For Proximal Impaction:
- High-dose oral polyethylene glycol (PEG) with electrolytes combined with sodium picosulphate is highly effective 5, 6
- Dosing regimen: 6-8 sachets of PEG with electrolytes on day 1, decreasing over 3-4 days, combined with 15-20 drops of sodium picosulphate on days 2-3 5
- This approach successfully disimpacts children within 3-4 days in outpatient settings, avoiding hospitalization 5, 6
Critical Pitfall to Avoid
Never start with dietary changes, behavioral modification, or stool softeners alone when impaction is present. 1, 2 These maintenance strategies are only effective after complete disimpaction has been achieved. Starting maintenance therapy without clearing the impaction will fail and may worsen overflow soiling. 2
Post-Disimpaction Management
Immediately after successful disimpaction, implement a maintenance bowel regimen to prevent recurrence: 1
- Preferred laxatives: Osmotic agents (PEG, lactulose, magnesium salts) and/or stimulant laxatives (senna, bisacodyl) 1
- Avoid bulk laxatives (psyllium) in children with limited mobility or severe constipation 1
- Increase daily water and fiber intake 1
- Optimize toileting: Educate to attempt defecation at least twice daily, preferably 30 minutes after meals 1
Contraindications for Enemas
Do not use enemas if the child has: 1
- Neutropenia or thrombocytopenia
- Paralytic ileus or intestinal obstruction
- Recent colorectal surgery
- Severe colitis or toxic megacolon
- Undiagnosed abdominal pain with peritoneal signs
When to Consider Surgery
Immediate surgical consultation is required if signs of peritonitis from bowel perforation are present, though this is rare. 1, 4 Stercoral perforation is a serious complication of untreated fecal impaction. 4
Long-Term Success
The combined approach of complete disimpaction followed by maintenance therapy improves constipation and encopresis in all compliant patients. 3 However, long-term compliance with laxative use is essential, as recurrence is common without ongoing preventive measures. 4, 2