What is fecal impaction

A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. Fecal impaction is defined as a large mass of compacted feces at any intestinal level that cannot be evacuated spontaneously ¹.  Fecal impaction occurs because of hardened fecal matter retained in the large bowel which cannot be evacuated by regular peristaltic activity. Patients with fecal impaction often give a history of inability to evacuate stools spontaneously and complain of total constipation. In most instances, an associated history of progressive abdominal distension with increasing abdominal discomfort or pain is present. Occasionally, patients may also present with a spurious or overflow diarrhea. If fecal impaction is not recognized and treated early, it can give rise to the formation of fecoliths or stone-like feces. Fecal impaction can be life-threatening, patient with a fecal impaction may present with circulatory, cardiac, or respiratory symptoms rather than with gastrointestinal symptoms ². If the fecal impaction is not recognized, the signs and symptoms may progress and resulting in death ³.

Fecal impaction is most often seen in people who are constipated for a long time (chronic constipation). Constipation is when you are not passing stool as often or as easily as is normal for you. Your stool becomes hard and dry. This makes it difficult to pass.

Fecal impaction commonly occurs among elderly individuals and other at-risk groups, such as children and patients with a neuro-psychiatric disease ⁴, rarely presenting as an acute emergency to a hospital. Severe constipation is a significant problem that affects almost 70% of elderly people who are under care in nursing homes ⁵. Among those affected, about 7% will have the condition detected during a digital rectal examination. Fecal impaction is more common among older women who are in institutional care and have associated neuropsychiatric disorders. It is a cause for increased morbidity among the elderly, and if allowed to progress, this can lead to complications causing mortality in the older age group ⁶.

Fecal impaction is a cause for increased morbidity and a significant cause of a decrease in quality of life among the elderly ⁷.

Physical examination findings often reveal a distended abdomen. In thinly built or emaciated individuals, hard fecal mass masses may be palpable along the colon. The diagnosis of fecal impaction is primarily based on clinical signs. A detailed history of bowel habits and a full physical examination which includes a digital rectal exam is mandatory.

Treatment for fecal impaction starts with removal of the impacted stool. After that, steps are taken to prevent future fecal impactions.

A warm mineral oil enema is often used to soften and lubricate the stool. However, enemas alone are not enough to remove a large, hardened impaction in most cases.

The fecal mass may have to be broken up by hand. This is called manual removal:

• Your doctor or nurse will need to insert one or two fingers into the rectum and slowly break up the mass into smaller pieces so that it can come out.
• This process must be done in small steps to avoid causing injury to the rectum.
• Suppositories inserted into the rectum may be given between attempts to help clear the stool.

Surgery is rarely needed to treat a fecal impaction. An overly widened colon (megacolon) or complete blockage of the bowel may require emergency removal of the impaction.

Most people who have had a fecal impaction will need a bowel retraining program. Your doctor and a specially trained nurse or therapist will:

• Take a detailed history of your diet, bowel patterns, laxative use, medicines, and medical problems
• Examine you carefully.
• Recommend changes in your diet, how to use laxatives and stool softeners, special exercises, lifestyle changes, and other special techniques to retrain your bowel.
• Follow you closely to make sure the program works for you.

Fecal impaction causes

Fecal impaction often occurs in people who have had constipation for a long time and have been using laxatives. The problem is even more likely when the laxatives are suddenly stopped. The muscles of the intestines forget how to move stool or feces on their own.

Fecal impaction commonly occurs among the elderly who are hospitalized patients or under institutional care ⁵. It is associated with generalized diseases, such as scleroderma and chronic renal failure, and conditions which cause an alteration in the normal anatomy such as congenital abnormalities in the anorectal region or previous surgical procedure of the intestine. In older adults who regularly consume nonsteroidal anti-inflammatory drugs, a higher occurrence of fecal impaction has been reported. Among hospitalized patients, administration in the elderly of medications with an opioid can result in fecal impaction, especially in those who have a history of chronic constipation and are bedridden ⁸.

The continuous contact between the hard feces and the colonic mucosa can cause an increase in mucus secretion. Fecal impaction also causes an increase in intraluminal pressure in the colon which causes a decrease in perfusion of the colonic mucosa and wall. The resulting localized inflammation can give rise to colitis, ulcerations, and possible perforation ⁹. When stercoral perforation occurs, the most frequent site is the sigmoid colon. Stercoral perforation that occurs in the rectosigmoid region is attributed to feces being hardest in the rectosigmoid. Also, the diameter of sigmoid is the narrowest in the colon. These factors lead to an increased intraluminal pressure and result in hypoperfusion of the antimesenteric wall casing perforation. The impacted fecal mass may cause compression of adjacent structures such as urinary bladder, causing urinary retention ¹⁰. In addition, sustained dilation of the colon may cause megacolon and increased secretion at this level, which, combined with the decreased sphincter tone in the elderly, gives rise to anal incontinence and diarrhea in this patient group ¹¹. Fecal impaction may also cause mechanical obstruction of the colon ¹² and compress nerve, vascular, or solid organ structures by a mass effect.

You are at more risk for chronic constipation and fecal impaction if:

• You not move around much and spend most of your time in a chair or bed.
• You have a disease of the brain or nervous system that damages the nerves that go to the muscles of the intestines.

Certain drugs slow the passage of stool through the bowels:

• Anticholinergics, which affect the interaction between nerves and muscles of the bowel
• Medicines used to treat diarrhea, if they are taken too often
• Narcotic pain medicine, such as methadone, codeine, and oxycontin

Barium Impaction

Sometimes impaction occurs after a barium study. Barium is not water soluble and can become a hard solid mass once the water is absorbed. Barium impaction is more likely to occur in patients who already have a functional or anatomical abnormality of the lower gastrointestinal tract. Barium impaction is also very common in people who have undergone some type of intestinal bypass procedure.

To prevent barium impaction, all patients should be encouraged to consume extra fluids. In some cases use of an osmotic laxative like sorbitol or milk of magnesia may be helpful. Barium impaction is usually seen on plain abdominal x-rays. Sometimes there may be perforation of the colon, which can also be visualized on the plain x-ray. If a perforation is noted, immediate surgery is required. If there is no perforation, barium removal is done similar to fecal impaction.

Fecal impaction signs and symptoms

Common symptoms of fecal impaction include:

• Abdominal cramping and bloating
• Leakage of liquid or sudden episodes of watery diarrhea in someone who has chronic (long-term) constipation
• Rectal bleeding
• Small, semi-formed stools
• Straining when trying to pass stools

Other possible symptoms of fecal impaction include:

• Bladder pressure or loss of bladder control
• Lower back pain
• Rapid heartbeat or lightheadedness from straining to pass stool

Fecal impaction possible complications

Fecal impaction complications may include:

• Tear (ulceration) of the rectal tissue
• Tissue death (necrosis) or rectal tissue injury
• Stercoral perforation
• Rectal discomfort
• Fecal incontinence
• Urinary incontinence

Fecal impaction diagnosis

The health care provider will examine your stomach area and rectum. A digital rectal examination is mandatory as the first diagnostic evaluation to confirm the diagnosis of fecal impaction. The rectal exam will show a hard mass of stool in the rectum. When a rectal exam does not reveal fecal impaction or hard fecal masses in the rectum, the possibility of fecal impaction more proximal in the bowel or other causes, such as strictures or volvulus of the colon, should be considered. The most useful and commonly used radiological imaging for evaluation is a CT abdomen with oral or rectal contrast. A plain x-ray of the abdomen can, at times, reveal fecal overloading of the colon with colonic distention of the in the segment proximal to the region of fecal impaction. Rarely, a contrast enema or sigmoidoscopy are indicated in a patient who has no history suggestive of the colonic disease.

You may also need to have a colonoscopy if there has been a recent change in your bowel habits. This is done to check for colon or rectal cancer.

• Once fecal impaction has been resolved, the cause should be explored.
• After a bowel preparation, a barium enema or a screening colonoscopy should be performed
• Thyroid and metabolic profiles should be evaluated.
• Other factors that need to be corrected include depression, lack of exercise, and inadequate access to toilet facilities.

Fecal impaction treatment

The treatment options are a digital evacuation of the impacted fecal mass or the rectal administration of stool softening agents, usually enemas or suppositories ¹³.

Manual Disimpaction

In many cases of fecal impaction, manual disimpaction is required. This is a helpful procedure if one can palpate hard stool in the rectal area. The procedure is best done using ample lubrication and gently removing the impacted stool with the index finger. Sometimes, the procedure can be aided with the use of an anoscope and suction. Most patients find immediate relief once fecal disimpaction is performed.

Enema for fecal impaction

If the abdominal x-ray reveals that the fecal impaction is located distally, then the use of enemas and suppositories can be helpful. The enema is best delivered with a Foley catheter past the hardened stool. The best method is to use ample water and combine it with docusate or sorbitol. It is important to administer small amounts of enema so as not to create discomfort in the patient. Once the enema is administered, one can help the process of evacuation by gently massaging the lower abdomen. This process may have to be repeated several times until only clear liquid passes.

For proximal fecal impaction, the ideal laxative is polyethylene glycol. One may have to administer from 1 to 3 liters of polyethylene glycol over a period of hours before a response is seen. If abdominal cramps and nausea occur, then no more polyethylene glycol should be ingested. Another laxative that can help with proximal impaction is magnesium citrate.

Polyethylene glycol can be given orally if conditions like volvulus or structural bowel obstruction due to any cause are ruled out. Administration of an appropriate laxative or fiber supplement with increased intake of water after the evacuation of the impacted fecal mass is administered to prevent recurrence. Early surgical evaluation and intervention are necessary if there are associated signs of peritonitis. Stercoral perforation is associated with a high mortality in the elderly if not recognized and treated early.

Fecal impaction surgery

In many people who have undergone repair of anal fistulas and removal of hemorrhoids, fecal impaction is quite rare but constipation is very common. The reason for fecal impaction is multifactorial and related to use of opiates, sphincter spasm, edema around the anal tissues, and a fear of going to the bathroom. In most mild cases, administration of an enema is sufficient; but in severe cases, one may need to perform manual disimpaction in the operating room. The patient will usually need some type of anesthesia to relax the anal sphincter complex before the fecal impaction can be removed.

These patients are encouraged to change their lifestyle, drink ample water, exercise, and eat a high fiber diet to prevent constipation.

Home remedy for constipation

Increase your dietary fiber intake

Today more than 80 percent of the U.S. population eats less than the recommended amount of vegetables, about 70 percent of the population eats more saturated fat, sodium and added sugar than is recommended. That is because the top three sources of calories in the U.S. are burgers, sandwiches and tacos; followed by desserts, sweet snacks and sugar-sweetened beverages, according to the most recent data from the National Health and Nutrition Examination Survey ¹⁴.

Adding fiber to your diet increases the weight of your stool and speeds its passage through your intestines. Slowly begin to eat more fresh fruits and vegetables each day. Choose whole-grain breads and cereals.

Adding fiber to the diet can have some side effects, such as abdominal bloating and/or gas, so start slowly and work your way up to your goal over a few weeks, until stools become softer and more frequent ¹⁵.

However, many people, including those with irritable bowel syndrome, cannot tolerate fiber supplements and do better by not increasing fiber in their diet

Your doctor may recommend a specific number of grams of fiber to consume each day. In general, aim for 30-35 grams of fiber per day in your daily diet.

What is Dietary Fiber ?

Dietary fiber, also known as roughage or bulk, includes the parts of plant foods your body can’t digest or absorb. Generally speaking, dietary fiber is a type of carbohydrate that your body can’t digest and dietary fiber is the edible parts of plants that are resistant to digestion and absorption in the small intestine. Though most carbohydrates are broken down into sugar molecules, fiber cannot be broken down into sugar molecules, and instead it passes through the body undigested. Fiber helps regulate the body’s use of sugars, helping to keep hunger and blood sugar in check ¹⁶.

Dietary fiber can be separated into many different fractions. Recent research has begun to isolate these components and determine if increasing their levels in a diet is beneficial to human health. These fractions include arabinoxylan, inulin, pectin, bran, cellulose, β-glucan and resistant starch. The study of these components may give us a better understanding of how and why dietary fiber may decrease the risk for certain diseases ¹⁷.

Children and adults need at least 20 to 30 grams of fiber per day for good health, but most Americans get only about 15 grams a day. The amount of fiber in a food is listed on the food’s nutrition facts label. Some fiber-rich foods are listed in the table below. Great sources are whole fruits and vegetables, whole grains, and beans.

Table 2. Fiber-Rich Foods

[Source: U.S. Department of Agriculture and U.S. Department of Health and Human Services. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at ¹⁸ ]

Exercise

Exercise most days of the week. Physical activity increases muscle activity in your intestines. Try to fit in exercise most days of the week. If you do not already exercise, talk to your doctor about whether you are healthy enough to start an exercise program.

Don’t ignore the urge to have a bowel movement

Take your time in the bathroom, allowing yourself enough time to have a bowel movement without distractions and without feeling rushed.

Stress Management

Stress is a normal psychological and physical reaction to the demands of life. A small amount of stress can be good, motivating you to perform well. But multiple challenges daily, such as sitting in traffic, meeting deadlines and paying bills, can push you beyond your ability to cope.

Stress has a way of becoming chronic as the worries of everyday living weigh us down. Or perhaps you’ve become accustomed to stress in your life, and you allow whatever is currently the most stressful problem to dictate what you will do each day. Everyone needs pleasure, productivity and creativity in their lives and chronic stress robs us of these.

[Source ¹⁹]

Where do you put yourself on this stress chart ?

To monitor your stress, first identify your triggers. What makes you feel angry, tense, worried or irritable ? Do you often get headaches or an upset stomach with no medical cause ?

Relaxation techniques are an essential part of stress management. Because of your busy life, relaxation might be low on your priority list. Don’t shortchange yourself. Everyone needs to relax and recharge to repair the toll stress takes on your mind and body.

Almost everyone can benefit from relaxation techniques, which can help slow your breathing and focus your attention. Common relaxation techniques include meditation, progressive muscle relaxation, tai chi and yoga. More-active ways of achieving relaxation include walking outdoors or participating in sports ²⁰.

It doesn’t matter which relaxation technique you choose. Select a technique that works for you and practice it regularly.

Positive thinking helps with stress management also and can even improve your health ²¹. Practice overcoming negative self-talk with examples provided.

Some studies show that personality traits such as optimism and pessimism can affect many areas of your health and well-being. The positive thinking that usually comes with optimism is a key part of effective stress management. And effective stress management is associated with many health benefits. If you tend to be pessimistic, don’t despair — you can learn positive thinking skills.

Positive thinking doesn’t mean that you keep your head in the sand and ignore life’s less pleasant situations. Positive thinking just means that you approach unpleasantness in a more positive and productive way. You think the best is going to happen, not the worst.

Positive thinking often starts with self-talk. Self-talk is the endless stream of unspoken thoughts that run through your head. These automatic thoughts can be positive or negative. Some of your self-talk comes from logic and reason. Other self-talk may arise from misconceptions that you create because of lack of information.

If the thoughts that run through your head are mostly negative, your outlook on life is more likely pessimistic. If your thoughts are mostly positive, you’re likely an optimist — someone who practices positive thinking.

Researchers continue to explore the effects of positive thinking and optimism on health. Health benefits that positive thinking may provide include:

• Increased life span
• Lower rates of depression
• Lower levels of distress
• Greater resistance to the common cold
• Better psychological and physical well-being
• Better cardiovascular health and reduced risk of death from cardiovascular disease
• Better coping skills during hardships and times of stress.

It’s unclear why people who engage in positive thinking experience these health benefits. One theory is that having a positive outlook enables you to cope better with stressful situations, which reduces the harmful health effects of stress on your body.

It’s also thought that positive and optimistic people tend to live healthier lifestyles — they get more physical activity, follow a healthier diet, and don’t smoke or drink alcohol in excess.

Not sure if your self-talk is positive or negative ? Some common forms of negative self-talk include:

• Filtering. You magnify the negative aspects of a situation and filter out all of the positive ones. For example, you had a great day at work. You completed your tasks ahead of time and were complimented for doing a speedy and thorough job. That evening, you focus only on your plan to do even more tasks and forget about the compliments you received.

• Personalizing. When something bad occurs, you automatically blame yourself. For example, you hear that an evening out with friends is canceled, and you assume that the change in plans is because no one wanted to be around you.

• Catastrophizing. You automatically anticipate the worst. The drive-through coffee shop gets your order wrong and you automatically think that the rest of your day will be a disaster.

• Polarizing. You see things only as either good or bad. There is no middle ground. You feel that you have to be perfect or you’re a total failure.

You can learn to turn negative thinking into positive thinking. The process is simple, but it does take time and practice — you’re creating a new habit, after all. Here are some ways to think and behave in a more positive and optimistic way:

• Identify areas to change. If you want to become more optimistic and engage in more positive thinking, first identify areas of your life that you usually think negatively about, whether it’s work, your daily commute or a relationship. You can start small by focusing on one area to approach in a more positive way.

• Check yourself. Periodically during the day, stop and evaluate what you’re thinking. If you find that your thoughts are mainly negative, try to find a way to put a positive spin on them.

• Be open to humor. Give yourself permission to smile or laugh, especially during difficult times. Seek humor in everyday happenings. When you can laugh at life, you feel less stressed.

• Follow a healthy lifestyle. Aim to exercise for about 30 minutes on most days of the week. You can also break it up into 10-minute chunks of time during the day. Exercise can positively affect mood and reduce stress. Follow a healthy diet to fuel your mind and body. And learn techniques to manage stress.

• Surround yourself with positive people. Make sure those in your life are positive, supportive people you can depend on to give helpful advice and feedback. Negative people may increase your stress level and make you doubt your ability to manage stress in healthy ways.

• Practice positive self-talk. Start by following one simple rule: Don’t say anything to yourself that you wouldn’t say to anyone else. Be gentle and encouraging with yourself. If a negative thought enters your mind, evaluate it rationally and respond with affirmations of what is good about you. Think about things you’re thankful for in your life.

Here are some examples of negative self-talk and how you can apply a positive thinking twist to them:

If you tend to have a negative outlook, don’t expect to become an optimist overnight. But with practice, eventually your self-talk will contain less self-criticism and more self-acceptance. You may also become less critical of the world around you.

When your state of mind is generally optimistic, you’re better able to handle everyday stress in a more constructive way. That ability may contribute to the widely observed health benefits of positive thinking.

Table 3. Putting positive thinking into practice

Negative self-talk	Positive thinking
I’ve never done it before.	It’s an opportunity to learn something new.
It’s too complicated.	I’ll tackle it from a different angle.
I don’t have the resources.	Necessity is the mother of invention.
I’m too lazy to get this done.	I wasn’t able to fit it into my schedule, but I can re-examine some priorities.
There’s no way it will work.	I can try to make it work.
It’s too radical a change.	Let’s take a chance.
No one bothers to communicate with me.	I’ll see if I can open the channels of communication.
I’m not going to get any better at this.	I’ll give it another try.

[Source ²¹]

Fecal impaction prognosis

Fecal impaction is a significant but preventable problem in the elderly population within hospitals and other institutions. The best way to treat it is to prevent it from developing in the first place. The cause of constipation should be identified early and managed appropriately. The patient should be educated about lifestyle measures and dietary habits to prevent fecal impaction. Unfortunately, recurrent fecal impaction is very common in elderly and institutionalized patients. Often these patients present to the emergency department because the presenting symptoms can mimic other sinister intestinal pathology.

Death secondary to fecal impaction complications was reported in 78 cases (29 % of the total) ². Prognosis was favorable in 184 cases and unknown in 18. Death was more frequent in the group aged over 65 years (32 % out of published deaths) compared to 28 % in the group of adults from 15 to 65 years old ². Respect to comorbidity, death was more frequent in patients with neuropsychiatric disease (30 %) and chronic renal failure (43 %). 54 % of patients with prior hospitalization had a fatal prognosis secondary to fecal impaction complication ².

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