FETAL IMPACTION

Incomplete evacuation of feces, leading to formation of a large, firm, immovable mass of stool in the rectum (70%),
sigmoid flexure (20%) or proximal colon (10%). The rectosigmoid colon dilates to accommodate the mass, which, in turn,
is not pliable enough to pass through the disproportionately small anal canal by the patient’s weak defecation effort.
Impacted stool may exist as a single mass (stercolith) or as a composite of small, rounded fecal particles (scybalum).

System(s) affected: Gastrointestinal Genetics: Fecal impaction of the cecum may be seen in cystic fi brosis

SIGNS & SYMPTOMS

• Fecal incontinence, interpreted as “diarrhea” • General malaise
• Postprandial abdominal pain • Agitation; confusion
• Tenesmus • Fever to 39.4°C (103°F)
• Colic • Tachycardia
• Nausea, vomiting • Tachypnea
• Anorexia, weight loss • Urinary frequency, incontinence
• Dehydration • Large mass of stool palpable in lower left quadrant
• Headache and rectal vault

CAUSES
• Diet lacking in fiber
• Drugs (stimulant laxatives, opiates, benzodiazepines, tricyclic antidepressants, phenothiazines, antihyperten-
sives, sucralfate, iron)
• Local or generalized neurogenic bowel disorders (e.g., stroke, parkinsonism, spinal cord lesions)
• Painful rectal conditions inhibiting voluntary defecation, (e.g., anal fi ssure, hemorrhoids)
• Neoplastic or inflammatory obstructing lesions (e.g., rectal bezoars)
• Hypothyroidism
• Hypokalemia
• Hypercalcemia
• Excess of gastrointestinal inhibitory hormones (prolac-tin, endorphins, glucagon, secretin)

RISK FACTORS
• Institutionalization • Chronic renal failure; renal transplant recipients
• Psychogenic illness • Urinary incontinence
• Immobility, inactivity • Cognitive decline
• Pica

DIAGNOSIS:

LABORATORY
• Leukocytosis to 15,000 WBC/cu.mm
• Hyponatremia
• Hypokalemia
• Stool may be positive for occult blood
• Anemia, due to blood loss

SPECIAL TESTS
• Sigmoidoscopy may be used to clarify the nature of a rectosigmoid mass beyond digital reach

IMAGING
• Plain abdominal radiography identifi es masses of stool or signs of obstruction if digital exam unrevealin
• Barium enema can differentiate feces from tumor

GENERAL MEASURES
• Manual fragmentation and extraction of fecal mass (after lubrication with lidocaine jelly) by physician or nurse
• More proximal masses can be disimpacted with water jet directed through fiberoptic sigmoidoscope
• Enemas - containing 20% water soluble contrast mate-rial (Gastrografi n, Hypaque) may further fragment stool
bolus
• For complete evacuation after partial fragmentation - bisacodyl suppositories or enemas with mineral oil, tap
water or sodium phosphate
• Ensure minimum fl uid intake of 1.5-2.0 liters/day

SURGICAL MEASURES
• Laparotomy - necessary only in extreme cases

ACTIVITY
 • Increased activity important

DIET:
• High fiber
• Home remedy: mix 2 cups bran, 2 cups applesauce and 1 cup unsweetened prune juice. Refrigerate. Take 2 to 3
tablespoons bid.

PATIENT EDUCATION
• Avoid catharsis
• No hot water, soap or hydrogen peroxide enemas! They may burn or irritate rectal mucosa, causing bleeding

DRUG(S) OF CHOICE
• 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
• For disimpaction in children, consider one of the follow-ing: ◊ 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

PREACAUTIONS
• Use magnesium citrate with caution in patients with renal insufficiency
• Be careful with lactulose; colonic distention can result from its bacterial fermentation

PATIENT MONITORING
• Less than one bowel movement every other day suggests impaction • Periodic rectal exam

PREVENTION/AVOIDANCE
• Establish regular, consistent toilet time by evoking gastrocolic reflex
• Maintain high fiber diet
• Reinforce exercise
• Install user-friendly commodes
• Use hydrophilic mucilloids (Metamucil) or stool-wetting agents (Colace) as needed
• Consider biofeedback; bowel training
• Periodic enemas, if indicated
• Periodic polyethylene glycol powder (MiraLax), 1 heap-ing teaspoon in 8 oz water daily for 2 weeks

POSSIBLE COMPLICATIONS
Complications of impaction
• Urinary tract obstruction • Megacolon
• Recurrent urinary tract infections • Rectal prolapse
• Intestinal obstruction • Pneumothorax
• Spontaneous perforation of colon • Hypoxia
• Stercoral ulceration • Hypovolemic shock
• Hernia • Iliac occlusion
• Volvulus

Complications of disimpaction
• Sepsis
• Hypotension
• Instrumental perforation
• Bleeding
• Postoperative obstruction

EXPECTED COURSE/PROGNOSIS
• Reimpaction likely, if bowel program not followed
• Prognosis poor for perforation with peritonitis
• Mortality with impaction and obstruction highest in