An otherwise healthy 64-year-old male presented to the emergency department with a 2-month history of constipation and tenesmus. He had seven admissions in the emergency department within the last 6 weeks and was already under laxative therapy, but it was ineffective. His physical examination was unremarkable, except for dehydration and diffuse abdominal pain. Blood tests demonstrated a mildly elevated serum creatinine. Abdominal radiography was performed and documented severe fecal impaction (Fig. 1). Computed tomography confirmed the presence of a fecal impaction with marked compression of the abdominal viscera, including the bile ducts, without signs of colonic perforation (Fig. 2). After rehydration, the patient underwent manual disimpaction under general anesthesia. His recovery was unremarkable.

Fig. 1.

Abdominal radiograph demonstrating severe fecal impaction. There are no signs of pneumoperitoneum.

Fig. 1.

Abdominal radiograph demonstrating severe fecal impaction. There are no signs of pneumoperitoneum.

Close modal
Fig. 2.

Contrast-enhanced computed tomography demonstrating severe fecal impaction with compression of the abdominal viscera. No signs of perforation were present.

Fig. 2.

Contrast-enhanced computed tomography demonstrating severe fecal impaction with compression of the abdominal viscera. No signs of perforation were present.

Close modal

Fecal impaction is a frequent and potentially serious medical condition. It is defined as a mass of compacted feces at any intestinal level that cannot be evacuated spontaneously [1].

Fecal impaction is a preventable disorder, and early diagnosis and treatment reduce the risk of complications, which include bowel obstruction leading to stercoral ulcer, perforation, peritonitis, or cardiopulmonary collapse with hemodynamic instability [2].

Constipation is frequent in adults >60 years, in whom the prevalence is about 30%, increasing to at least 50% in nursing home residents [3]. In addition to age, risk factors for chronic constipation include female gender, physical inactivity, low education and income, concurrent medication use, and depression [4]. Decreased mobility and the inability to sense and respond to the presence of stool in the rectum will ultimately lead to impaction. This explains why the patients with the highest risk are the elderly and patients with neuropsychiatric disorders [5].

A digital rectal examination confirms the diagnosis of fecal impaction most of the times. However, impaction can occur in the proximal rectum or sigmoid colon, and a digital rectal examination will be nondiagnostic. In these cases, the next step should be an abdominal radiography as it can confirm the diagnosis and exclude major complications. Management involves mechanical removal of the stools, followed by implementation of a bowel maintenance regimen to prevent recurrence.

This study did not require informed consent or review/approval by the appropriate ethics committee.

The authors have no conflicts of interest to declare.

No funding was received.

Andreia Ribeiro designed this work and was responsible for clinical data acquisition and wrote the clinical vignette. In addition, she revised the whole manuscript.

Gonçalo Freire was responsible for the acquisition and processing of the images. He wrote the legends and revised the whole work.

Marlene Alves was responsible for the review of literature. She also revised the manuscript.

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