Question

The patient was admitted to the Med/Surg. Floor for treatment and resolution of fecal impaction. An oncology consult order was entered. The patient stated she has abdominal pain of an 8 out of 10 on the Numeric Rating Scale.

The patient presents to the ER with severe abdominal pain, especially in the left lower quadrant. An abdominal CT was ordered, and it was found that there is a 5-centimeter mass in the lower sigmoid colon with fecal impaction.

In the scenario of Julia Jackson, which areas of care can be delegated to other interprofessional healthcare personnel to help resolve her immediate concerns?

Answer 1

Fecal impaction (FI) is a common cause of lower gastrointestinal tract obstruction lagging behind stricture for diverticulitis and colon cancer. It is the result of chronic or severe constipation and most commonly found in the elderly population. Early recognition and diagnosis is accomplished by way of an adequate history and physical examination in conjunction with an acute abdominal series. Prompt identification and treatment minimizes the risks of complications such as bowel obstruction leading to aspiration, stercoral ulcers, perforation, and peritonitis. Treatment options include gentle proximal softening in the absence of complete bowel obstruction, distal washout, and manual extraction. Surgical resection of the involved colon or rectum is reserved for cases of FI complicated by ulceration and perforation leading to peritonitis. Recurrence is common, and can be managed by increasing dietary fiber content to 30 gm/day, increased water intake, and discontinuation of medications that can contribute to colonic hypomotility.ecal impaction (FI) is a common cause of lower gastrointestinal tract obstruction lagging behind stricture for diverticulitis and colon cancer. It is the result of chronic or severe constipation and most commonly found in the elderly population. Early recognition and diagnosis is accomplished by way of an adequate history and physical examination in conjunction with an acute abdominal series. Prompt identification and treatment minimizes the risks of complications such as bowel obstruction leading to aspiration, stercoral ulcers, perforation, and peritonitis. Treatment options include gentle proximal softening in the absence of complete bowel obstruction, distal washout, and manual extraction. Surgical resection of the involved colon or rectum is reserved for cases of FI complicated by ulceration and perforation leading to peritonitis. Recurrence is common, and can be managed by increasing dietary fiber content to 30 gm/day, increased water intake, and discontinuation of medications that can contribute to colonic hypomotility.ecal impaction (FI) is a common cause of lower gastrointestinal tract obstruction lagging behind stricture for diverticulitis and colon cancer. It is the result of chronic or severe constipation and most commonly found in the elderly population. Early recognition and diagnosis is accomplished by way of an adequate history and physical examination in conjunction with an acute abdominal series. Prompt identification and treatment minimizes the risks of complications such as bowel obstruction leading to aspiration, stercoral ulcers, perforation, and peritonitis. Treatment options include gentle proximal softening in the absence of complete bowel obstruction, distal washout, and manual extraction. Surgical resection of the involved colon or rectum is reserved for cases of FI complicated by ulceration and perforation leading to peritonitis. Recurrence is common, and can be managed by increasing dietary fiber content to 30 gm/day, increased water intake, and discontinuation of medications that can contribute to colonic hypomotility.ecal impaction (FI) is a common cause of lower gastrointestinal tract obstruction lagging behind stricture for diverticulitis and colon cancer. It is the result of chronic or severe constipation and most commonly found in the elderly population. Early recognition and diagnosis is accomplished by way of an adequate history and physical examination in conjunction with an acute abdominal series. Prompt identification and treatment minimizes the risks of complications such as bowel obstruction leading to aspiration, stercoral ulcers, perforation, and peritonitis. Treatment options include gentle proximal softening in the absence of complete bowel obstruction, distal washout, and manual extraction. Surgical resection of the involved colon or rectum is reserved for cases of FI complicated by ulceration and perforation leading to peritonitis. Recurrence is common, and can be managed by increasing dietary fiber content to 30 gm/day, increased water intake, and discontinuation of medications that can contribute to colonic hypomotility.

Enemas.

Cleansing enema–induced perforations are less commonly reported than are iatrogenic perforations from colonoscopy or barium enemas.4 But their true incidence is difficult to establish, in part because nursing home personnel who refer a patient for treatment may provide false or misleading information in order to avoid future litigation.12 In one study, of 10 pa tients presenting with perforation after receiving a retrograde irrigation enema at a nursing home, the relevant information linking the enema to the patient’s condition was given for only 20% of patients. For the others, “the information was vague and sometimes misleading.”12 Therefore, when evaluating a nursing home resident with symptoms concordant with perforation, clinicians should consider the possibility of enema-induced perforation. Requesting copies of recent nursing notes may help to address such concerns.

1. Assess potential cause of constipation (e.g., recent opioid dose increase, use of other constipating medications, or new bowel obstruction).
2. Increase Senokot-S (or senna and docusate tablets, if using separately), and add one or both of the following:
   1. Milk of magnesia oral concentrate (1170/5 mL), 10 mL by mouth 2 to 4 times per day.
   2. Polyethylene glycol (MiraLAX), 17 g in 8-oz beverage daily.
3. If no response to above, perform digital rectal examination to rule out low impaction. Continue above steps AND:
   1. If impacted, disimpact manually if stool is soft. If not, soften with mineral oil fleets enema before disimpaction. Follow up with milk of molasses enemas until clear with no formed stools.
   2. Consider use of rescue analgesics before disimpaction.
   3. If not impacted on rectal examination, patient may still have higher level impaction; if history is appropriate, consider abdominal imaging and/or administer milk of molasses enema with magnesium citrate 8 oz by mouth. Consider bowel management consult.
4. If patient is neutropenic or thrombocytopenic, arrange for bowel management consult.

• Start one of the following regimens if the patient has not had a stool in 3 days or on the first day that any patient starts taking drugs associated with constipation:
  • Stool softeners (e.g., docusate sodium, one to two capsules per day). For opioid-related constipation, stool softeners may be used in combination with a stimulant laxative. Bulk-producing agents are not recommended in a regimen used to counteract the bowel effects of opioids.
  • Two tablets of a senna preparation twice daily.
  • One bisacodyl tablet at bedtime.
  • Milk of magnesia, 30 to 45 mL, if a bowel movement is not achieved in 24 hours after other methods are instituted.
• If the amount of stool is still inadequate, increase stool softeners up to six capsules per day or a senna preparation (e.g., Senokot) gradually to a maximum of eight tablets (four tablets twice a day); bisacodyl may be increased gradually to three tablets.
• If the amount of stool is still inadequate, a glycerin or bisacodyl suppository or enema (phosphate/biphosphate, oil retention, or tap water) is used with caution, especially in patients with neutropenia or thrombocytopenia.

Medical management includes the administration of saline or chemical laxatives, suppositories, enemas, or agents that increase bulk.