RISK FACTORS : Institutionalization, Psychogenic illness, Immobility, inactivity, Pica, Chronic renal failure; renal transplant recipients, Urinary incontinence, Cognitive decline
GENERAL MEASURES :
β’ Manual fragmentation and extraction of fecal mass (after lubrication with lidocaine jelly) by physician or
nurse
β’ More proximal masses can be disimpacted with water jet directed through fiberoptic sigmoidoscope
β’ Enemas - containing 20% water soluble contrast material (Gastrografi n, Hypaque) may further fragment stool
bolus
β’ For complete evacuation after partial fragmentation - bisacodyl suppositories or enemas with mineral oil, tap water or sodium phosphate
β’ Ensure minimum fluid intake of 1.5-2.0 liters/day
SURGICAL MEASURES Laparotomy - necessary only in extreme cases
ACTIVITY Increased activity important
DIET:
β’ High fiber
β’ Home remedy: mix 2 cups bran, 2 cups applesauce and 1 cup unsweetened prune juice. Refrigerate. Take
2 to 3 tablespoons bid.
PATIENT EDUCATION:
β’ Avoid catharsis
β’ No hot water, soap or hydrogen peroxide enemas! They may burn or irritate rectal mucosa, causing bleeding.
DRUG(S) OF CHOICE :
β’ A daily one-liter bolus of polyethylene glycol-electrolyte (GoLYTELY, Colyte) solution given over 4-6 hours for up to 3 days is reported to be highly effective and acceptable oral therapy in adults
β’ For disimpaction in children, consider one of the following:
. Combination (enema, suppository, oral laxative)
- Day 1: 1-2 enemas, 1 oz/10 kg to 4.5 oz maximum
- Day 2: Bisacodyl suppository per rectum every day or twice daily
- Day 3: Bisacodyl tablet orally every day or twice daily
- Repeat 3-day cycle if needed 1-2 times
. High-dose mineral oil
- 15-30 mL orally per year of age per day to 8 oz maximum, once or twice daily for 3 days
. Enemas
- 1-2 oz/10 kg to 4.5 oz maximum, once or twice daily for 1-2 days
. Polyethylene glycol 3350 (GoLYTELY) is safe and effective in children at doses of 1.0-1.5 g/kg per day for 3 days
Precautions:
β’ Use magnesium citrate with caution in patients with renal insufficiency
β’ Be careful with lactulose; colonic distention can result from its bacterial fermentation
PATIENT MONITORING :
β’ Less than one bowel movement every other day suggests impaction
β’ Periodic rectal exam
PREVENTION/AVOIDANCE :
β’ Establish regular, consistent toilet time by evoking gastrocolic reflex
β’ Maintain high fiber diet
β’ Reinforce exercise
β’ Install user-friendly commodes
β’ Use hydrophilic mucilloids (Metamucil) or stool-wetting agents (Colace) as needed
β’ Consider biofeedback; bowel training
β’ Periodic enemas, if indicated
β’ Periodic polyethylene glycol powder (MiraLax), 1 heaping teaspoon in 8 oz water daily for 2 weeks
POSSIBLE COMPLICATIONS :
β’ Complications of impaction
. Urinary tract obstruction
. Recurrent urinary tract infections
. Intestinal obstruction
. Spontaneous perforation of colon
. Stercoral ulceration
. Hernia
. Volvulus
. Megacolon
. Rectal prolapse
. Pneumothorax
. Hypoxia
. Hypovolemic shock
. Iliac occlusion
β’ Complications of disimpaction :
. Sepsis
. Hypotension
. Instrumental perforation
. Bleeding
. Postoperative obstruction
EXPECTED COURSE/PROGNOSIS :
β’ Reimpaction likely, if bowel program not followed
β’ Prognosis poor for perforation with peritonitis
β’ Mortality with impaction and obstruction highest in very young and very old (up to 16%)
AGE-RELATED FACTORS
Pediatric:
β’ Habitual neglect of defecation urge, because of interference with play, may promote impaction
β’ Fecal impaction has been reported to occur in over half of all children with chronic constipation
Geriatric:
β’ Measure thyroid function, electrolyte activity and urea nitrogen levels in elderly patients presenting with
impaction
β’ Much more likely to occur in patients over 80