A Rare Ileus Etiology: Giant Fecaloma

Abstract

Turkish Abstract

Introduction

Fecaloma was first described in 1967 as  a mass of stool most frequently noted in the rectum and the sigmoid colon. Usually, the fecal matter accumulates in the intestine, then stagnates and increases in volume until the intestine becomes deformed and acquires characteristics,  similar to those of a tumor ¹.

There are several causes of fecaloma and have been described in association with Hirschsprung's disease ², psychiatric patients, Chagas disease, both inflammatory and neoplastic diseases, and in patients suffering from chronic constipation ³.

This is a report of a giant, solitary, and stubborn fecaloma not responding to medical treatment.

Case Report

A seventy-seven-year-old male patient applied to the emergency service because of nausea, vomitting, abdominal distention and colicky abdominal pain presented for about four days. It has been learned from his medical history that he  had chronic hypopotassemia that continued for 5-6 months. There was no past surgery  history. The patient was mildly hypotensive (80/50 mm mercury) and tachycardic (114/min) demostrating dehydration. Body temperature was normal. On physical examination, there was mildly diffuse tenderness in  all of abdominal quadrants.No bowel sounds were noted The anal canal was empty. In the laboratory; leukocyte count was 3,4 10 ^ 3 / uL, blood potassium level was 2.1 mmol / L, blood creatine level was 1,9 mg / dL. The other laboratory parameters were unremarkable. There were multiple air fluid levels at small intestine-colon segments on  radiographs (Figure 1).

Figure 1 Multiple air fluid levels at small intestine-colon segments at radiographic imaging

 

The patient's creatine value was high. Because of that the patient interned without ıntravenous-contrast abdominal computed tomography (CT). Nasogastric catheter was fitted. Oral intake was stopped. Rehydration,digital evacuation and enema teraphy was started. Hypokalemia treatment was performed by nephrology consultants.With hypokalemia treatment, blood levels of potassium were elevated to normal values.  In the follow-up the creatine level increased to 2.5 mg / dL. Despite aggressive treatment, abdominal distention increased. So the patient underwent urgent laparotomy (Figure 2).

Figure 2 Increased multiple air fluid levels at radiographic imaging

          

At the surgery, there was a huge fecaloma approximately 10 * 5 cm at distal segment of the descending colon. There was large dilation of the proximal small intestine and colonic segments because of the fecaloma obstruction. Fecaloma was softened by palpation and advanced to the distal colon. In the postoperative follow-up, the enema treatment resumed and radiographs were normal (Figure 3).

Figure 3 Last imaging of the patient before externation

 

Discussion

Fecaloma represents an accumulation of hard stool in the rectum and, rarely, in the sigmoid colon ⁴. Fecal impactation is a common condition and fecaloma is an extreme variety of impactation that refers to an accumulation of stool material which forms a mass separable from the rest of the bowel contents. This condition is uncommon and the majority of reported cases have been in adults. Fecaloma presents variably from urinary retention ⁵ to toxic megacolon ⁶ or abdominal mass ^7,8.Constipation was the main symptom referred by our patient. In fact, constipation is one of the most frequently experienced gastrointestinal complaints and one of the most frequent indications for medical consultation ⁹.

The composition of the mass is quite inconstant, but usually consists of fecal matter and intestinal debris ¹⁰. Often is formed in a laminated fashion due to deposits of calcium soaps in layers. Distal colon and rectum are the most common sites for fecalomas ¹¹. Common complications of fecalomas and fecal impaction include obstruction ¹², perforation ^13,14, ulceration ¹⁵ and hydronephrosis ^16,17. Most cases of fecaloma are treated conservatively with digital evacuation and enemas. In severe and unremitting cases, surgery is required to prevent significant complications (bowel obstruction, ulceration, rectosigmoid megacolon). Fecaloma should be considered in the differential diagnosis of any patient with history of chronic constipation and abdominal mass ⁴. Another approach such as endoscopic removal had also been described ¹⁸.

Obstruction because of stool should be considered when considering ileus pre-diagnosis in geriatric and bed-dependent patients .With additional imaging, this condition of ileus must be demonstrated. The necessary medical approaches and treatments must be applied to remove the etiology. The laparotomic surgical approach should be added to the algorithm of ileus treatment in cases of ileus with fecal obstruction. In our case,  we want to show necessity of surgical approach to the ileus patients because of fecal obstruction.

References