What is Fecal Impaction?
The impacted bowel is a medical condition in which the feces form into a dry mass, occupying the rectum. This condition is also known as the fecal impaction, being mainly caused by severe and chronic constipation. In some patients, the hard mass can reach as far as the sigmoid colon. The stone-like mass (fecalith or fecaloma) can aggravate other medical conditions, such as the diverticula, upon collecting in one of the outpouchings.
Picture of Impacted Bowel – Diagram showing the Fecal Impaction
Because of the hard mass, the bowels can suffer from the partial or complete obstruction (the contents of the colon are blocked and they tend to back up). The condition is progressive and if no treatment measures are taken, the fecal contents can reach the small intestine. Because of the blockage, the colon expands, the distension leading to the appearance of what is known as a megacolon. The distension has a negative impact on the motility of the colon, leading to the aggravation of the constipation (the fecal contents cannot be evacuated).
Upon the blood flow to the megacolon being compromised, the patient can suffer from rare complications, such as the ischemic bowel disease. It is possible that infection appears due to the blocked feces, affecting the entire abdominal cavity. Such complications required emergency medical assistance, otherwise the symptoms can become life-threatening. It is important, however, to remember that the impacted bowel is not considered a common complication of constipation. This is a rare condition and it is more often encountered in the older population; it is also seen in those who are bedridden or in those who abuse certain medication.
Pathology
The impacted bowel can appear in the situation that a blockage exists at the level of the small or large intestine. Before reaching the descending colon, the gastrointestinal contents are semi-solid – this means that the obstruction would have to be significant in order for the contents to be blocked. On the other hand, at the level of the descending and sigmoid colon, the contents are more solid and they form the feces. In the situation that a person suffers from fecal impaction, the feces might reach the rectum but the evacuation will not take place, as it normally should. Because of the water absorption, the feces become even drier, adding to the already existent problem. It is important to determine the causes of the severe constipation that has led to the impacted bowel in the first place, so as to prevent similar episodes in the future.
As the number one cause that leads to the appearance of the impacted bowel is constipation, it is essential to be aware of the actual causes of constipation. Such problems can appear as a side-effect of certain medication (antihistamines, anticholinergic drugs, narcotic medication) but also because of insufficient fiber intake or dehydration. Frequent bouts to diarrhea can lead to constipation, as well as other problems of the digestive system, diabetes or endocrinologic disorders (most commonly affecting the thyroid). An obstruction at the level of the intestinal tract, chronic vomiting and spinal cord injuries are also to be found among the causes of the impacted bowel. The adhesions from the previous surgical interventions can have a negative effect on the health of the colon, favoring the appearance of chronic constipation and, ultimately, leading to the impacted bowel.
Symptoms of an Impacted Bowel
The human bowel presents an important capacity of storing feces, combined with the ability to stretch. This is the number one reason why the symptoms of the impacted bowel at the onset of the condition are not specific. Patients report chronic constipation, with intermittent episodes of diarrhea. In the situation that the obstruction is partial, the stool might be modified (pencil-thin stool). Upon excessively straining, the patients might present very little or no stool. The bowel movements can be intensely painful and rectal bleeding can occur due to the excessive straining.
Picture of Fecal Impaction – Diagram showing the normal bowel (left side) and Impacted bowel (right side)
In the situation that gastrointestinal symptoms begin to appear, this might suggest that the condition has progressed and that there is a high risk of complications. Among the most gastrointestinal symptoms, there are: severe pain at the level of the abdomen, nausea and vomiting, bloating, indigestion or lack of appetite, state of general malaise and infections at the level of the urinary tract. More severe symptoms signify that complications have already occurred and they require emergency medical intervention. These include: rapid heartbeat, hyperventilation, high-running fever, confusion, delirium, agitation, vascular shock.
Diagnosis of Fecal Impaction
These are the most common methods that can be used for the diagnosis of the impacted bowel:
- Medical history
- Frequency of bowel movements and gas
- Description of the stool (quantity, firmness, color)
- Presence of blood in the stool
- Gastrointestinal symptoms
- Usage of laxatives or enemas
- Methods of relieving constipation
- Diet & fluids
- Medication
- Physical examination
- Palpation of the abdomen – identification of the stone-like mass
- General signs of health
- Blood testing
- Antibodies
- Tumor markers
- Digital rectal exam
- Check for fecal impaction
- Abdominal ultrasound and/or sigmoidoscopy
- Visualization of the colon and precise identification of the location of the impacted bowel
- Barium enema
- Necessary for the more efficient visualization of the problem areas
- After the dye has been inserted at the level of the rectum, an X-ray is performed for the colon and, more specifically, the rectum
- EKG
- Activity of the heart
- Identify potential cardiac complications.
How to Treat an Impacted Bowel?
These are the most common methods of treatment recommended for the impacted bowel:
Laxatives
- First solution for the clearing of the blockage
- Osmotic laxatives – most recommended
- Moisten the stool
- Magnesium citrate
- It can take from as little as a couple of minutes to several hours to function
- May lead to cramps and severe pain (the contents of the intestines cannot be eliminated due to the fecal mass representing a blockage on its own)
- Polyethylene glycol
- Increase the water content of the stool, without associated side-effects such as cramping
- May require 24-48 hours to take effect
- Not recommended in the situation where the elimination of the bowel contents is an emergency (due to potential complications)
Manual removal of the feces
- Indicated in the situation that the laxatives do not clear the blockage
- This procedure is also known as manual disimpaction and it is recommended in the situation when the immediate removal of the fecal mass is mandatory
- For this procedure, the anus is lubricated and the fecal mass is broken, using a glove finger (scoop-like motion)
- The procedure is performed without general anesthesia (sedation might be used in certain cases)
Enema/water irrigation
- Recommended in the situation that the blocked feces cannot be removed manually
- The blocked feces are moistened and thus they can be dislodged, with the obstruction being relieved
- The water irrigation requires for the abdomen to be massaged, in order for the blocked feces to be dislodged
- The enema might not soften the stool sufficiently for it to be passed through the anal canal (or, if it is successful at dislodging the fecal mass, it may be too large in size for it to be eliminated)
- Mineral oil enema – more recommended (increased lubrication)
Suppositories
- Most recommended – glycerin suppositories
- Increase the water content to the stool
- Stimulation of the peristalsis, thus promoting the expulsion of the fecal mass
- Works more quickly than the oral laxatives.
Prevention of Impacted Feces
In order to avoid suffering from an impacted bowel, it is important to take all the necessary measures and prevent constipation. You can switch the medication and make sure that you choose one that does not have such side-effects. In regard to the diet, you need to include more fruits and veggies that have sufficient quantities of fiber to offer. You should drink plenty of water every day, in order to avoid dehydration. On the other hand, the intake of foods that favor constipation should be reduced (especially those that have a high fat or sugar content). Physical exercise is required on a daily basis, so that the digestive system functions in a healthy manner and the bowel movements take place.
For patients who are bedridden, the close monitoring of the bowel movements is essential. The massage to the abdomen can prevent the impacted bowel, as well as the passive movements that are performed by a physical therapist.
The prevention measures are essential to prevent future episodes of the impacted bowel. One of the most recommended measures is taking polyethylene glycol on a daily basis, due to the fact that there are no side-effects. On the other hand, stimulant laxatives should be avoided as much as it is possible. These can lead to dependency, having a negative impact on the normal functioning of the colon. Because of the excessive usage of stimulant laxatives, one runs the risk of being unable to defecate without actually using a laxative.
Complications of Impacted Bowel
Apart from the complications that were mentioned in the first part of the article, you should know that the impacted bowel can also lead to the following: tears at the level of the anal sphincter, bleeding at the same location, hemorrhoids and even tears at the level of the colon wall. Other complications include the necrosis or ulceration that can appear in the rectum. Paying attention to your bowel movements and visiting the doctor upon suffering from severe constipation is a good way to prevent such complications from ever occurring.
Cardiac complications can also arise, due to the constant stimulation of the vagal nerve. Among the symptoms of these cardiac complications, there are: irregular rhythm of the heart, state of general weakness and even fainting. In extremely rare cases, the patient can suffer from cardiac tamponade. The ventricles of the heart can no longer expand to their maximum volume, with the compression of the heart preventing the adequate amount of blood to be pumped.
