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Constipation is common in older adults, and may lead to fecal impaction, and in rare instances, progress to a fecaloma, which is an inspissated accumulation of hardened feces [1]. Fecaloma most commonly forms in the distal colon and rectum through accrual of stagnant fecal matter which distorts the intestinal contour [2].

Predisposing risks factors include older age, bowel dysfunction, chronic constipation, medications, gynecological issues, and neurological and psychological disturbances [3]. Severe constipation resulting in bowel impaction may lead to complications such as megacolon, intestinal obstruction, bowel perforation, urinary obstruction and retention, and infection in the urinary tract, colon, or bloodstream [2,4-6]. Older adults are particularly susceptible to sepsis from a urinary source and may present with life-threatening systemic complications, such as acute encephalopathy and septic shock.

We report a rare case of constipation-induced rectal fecaloma in an older female that was complicated by obstructive uropathy and ensuing septic encephalopathy.

An 88-year-old female presented to the emergency department in an acute confusional state, with generalized weakness and a mild episode of rectal bleeding. Her medical comorbidities were hypertension, polymyalgia rheumatica, chronic constipation, and unprovoked pulmonary embolism anticoagulated with warfarin. On examination, she was cachectic-appearing, and exhibited disorientation to time and place, slow response rate, and abdominal distension. Neurological exam was otherwise unremarkable.

Upon admission, she met sepsis criteria due to tachycardia in the 110-120 beats per minute and leukocytosis of 16.5 x10(9)/L. Other laboratory findings were hemoglobin of 12.2 g/dL, sodium of 126 mmol/L, creatinine of 2.3 mg/dL and an INR >20. A non-contrast computerized tomography (CT) scan of the pelvis revealed a large rectal stool ball measuring 10 cm x 12 cm, filling much of the pelvis, causing bladder distension and left-sided hydronephrosis (Figures 1 and 2).

Figure 1: Non-contrast CT scan of the pelvis (transverse view) demonstrating a large rectal fecalith, measuring 10 cm x 12 cm.

Figure 2: Non-contrast CT scan of the abdomen and pelvis (coronal view) demonstrating a large rectal fecalith, measuring 10 cm x 12 cm, and leftsided hydronephrosis.

She was admitted to the intensive care unit due to sepsis from a urinary source. She received intravenous fluids, vitamin K and fresh frozen plasma, and underwent digital disimpaction, with two water enemas, one bisacodyl and one magnesium enema. Foley catheter was placed and two liters of urine were evacuated. Blood and urine cultures grew pan-sensitive Escherichia coli, and she was treated with intravenous ceftriaxone. Following disimpaction, her hydronephrosis and kidney injury resolved. Her mentation gradually improved, and she was subsequently discharged to a skilled nursing facility (Figures 1 and 2).

Fecaloma is a rare and serious complication of constipationinduced fecal impaction, as seen in our patient [6]. It usually occurs on the left side of the colon due to its narrower diameter and accumulation of firmer feces prior to evacuation [2]. Older adults are especially prone to fecal impaction due to chronic constipation, dehydration, decreased mobility, medical comorbidities and high-risk medications, such as narcotics, calcium channel blockers, diuretics, iron, and aluminum antacids. Older adults are also susceptible to serious complications, such as urinary obstruction, bacteremia, and acute encephalopathy as seen in our patient [5].

The diagnosis of fecaloma is confirmed on abdominal imaging which demonstrates a circumscribed intraluminal stool mass, and is corroborated with suggestive history and exam findings, such as constipation, abdominal pain, and generalized tenderness [6]. Conservative management of fecalomas is often successful and includes bowel rest, laxatives, enemas, and manual disimpaction with digital evacuation [2]. In complicated cases, however, endoscopic fragmentation and surgical intervention are required [4].

Conclusion

This case report highlights the importance of early recognition and treatment of constipation, especially in older adults with multiple risk factors. While seemingly benign, constipation can lead to fecal impaction and rarely fecaloma with severe sequalae such as septic encephalopathy. This report also demonstrates fecal impaction and fecaloma should be considered in the differential diagnosis of older patient with chronic constipation who present with urinary obstruction and acute encephalopathy.