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| CASE REPORT |
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| Year : 2020 | Volume
: 53
| Issue : 2 | Page : 70-73 |
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Fecaloma causing megacolon and bilateral hydronephrosis
Kuan-Chi Tu, Jinn-Rung Kuo
Department of Neurosurgery, Chi Mei Medical Center, Yongkang, Taiwan
| Date of Submission | 19-Jul-2019 |
| Date of Decision | 25-Sep-2019 |
| Date of Acceptance | 21-Nov-2019 |
| Date of Web Publication | 23-Apr-2020 |
Correspondence Address:
Dr. Jinn-Rung Kuo
No. 901, Zhonghua Rd., Yongkang District, Tainan City 71004
Taiwan
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/fjs.fjs_58_19
Fecaloma is a rare complication of chronic constipation with fecal impaction, which usually is underestimated. The megacolon would be noted as a result of that the harden stool commonly obstructs the rectum and sigmoid colon. So far, numerous cases about obstructive uropathy caused by fecaloma have been reported. We present the case of a 63-year-old female with a history of hemorrhagic stroke, who experienced acute bilateral hydronephrosis and fecaloma. She was successfully treated by colonoscopy irrigation and manual manipulation. In this literature, we focus on the association with the change of bowel movement after brain injury and remind neurosurgeons the clinical care about bowel program.
Keywords: Fecaloma, hemorrhagic stroke, hydronephrosis
How to cite this article:
Tu KC, Kuo JR. Fecaloma causing megacolon and bilateral hydronephrosis. Formos J Surg 2020;53:70-3 |
| Introduction | |  |
Constipation is a common and higher prevalence in the elderly, especially in elderly female, making considerable financial burden in major healthcare utilization.[1] The neuroendocrine network may be affected after brain injury and caused gastrointestinal disorder.[2],[3] If we do not pay enough attention to it, lots of complication will develop, even fecaloma formation. The case who we reported was a long-term bedridden patient with the high risk of constipation suffered from fecaloma.
| Case Presentation | | |
A 63-year-old female patient was a case of left hypertensive thalamic hemorrhage and in a bedridden status with Foley in the place and fed through a nasogastric tube for a long time after decompressive craniectomy with hematoma removal. She presented to the emergency room due to constipation for several days on October 22, 2018. Upon examination, her abdomen was distended and normoactive bowel sounds with tympanic percussion. Besides, urinalysis revealed pyuria, so the impression of urinary tract infection (UTI)-related paralytic ileus was suspected. She was treated with intravenous antibiotics and adequate hydration.
On October 26, 2018, plain film of the abdomen was obtained and demonstrated a large fecaloma about 23-cm retention in the rectum and sigmoid colon [Figure 1]. Enema and laxatives were tried but in vain. Dysuria and pitting edema of the left foot developed later, which was associated with acute kidney injury (AKI) as creatinine climbed to 2.65 mg/dL compared with previous 1.01 mg/dL. Intravenous fluid with colloid and Lasix for diuresis were administered. The sonography showed bilateral hydronephrosis. Abdominal computed tomography disclosed stool impaction in the rectum with megacolon and bilateral hydronephrosis without obvious obstructive lesion [Figure 2], [Figure 3], [Figure 4]. | Figure 1: There is a large fecaloma (length: 23 cm) retention in the rectum and sigmoid colon
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 | Figure 2: A larger fecaloma impacts the rectum and causes megacolon, which compresses bilateral ureters (yellow arrows, →)
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 | Figure 4: A larger fecaloma impacts the rectum leads to bilateral hydronephrosis
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The patient received colonoscopy irrigation and manual manipulation, and the fecaloma was eliminated on November 5, 2018. Under appropriate antibiotic and fluid supplements, the subsequent laboratory data demonstrated an improvement of renal function and complete treatment for UTI. Under relatively stable conditions, she was discharged on November 15, 2018, and further outpatient department follow-up was arranged.
| Discussion | | |
We identified available and English literatures through specific word, including “Fecaloma and Hydronephrosis” to search the titles of case reports listed in PubMed in recent 10 years. Only four case reports were filtered out, in which five patients were discussed, and 2 of 5 cases expired, while 1 case died from sepsis and acute renal failure secondary to spontaneous rupture of urinary bladder related with massive fecal impaction, and the other was caused by severe urosepsis and acute renal failure.[4],[5],[6] The survival cases had hydronephrosis resolved after adequate treatment [Table 1]. There is no case discussed about the relationship between fecal impaction after brain injury and hydronephrosis. In our literature, we reviewed the mechanism and focused on the devasting fecal impaction with hydronephrosis that the patients with Cerebral vascular accident (CVA) and clinician will face.
The incidence of constipation in the hemorrhagic stroke is 66% during one systemic review, though many patients have complete functional independence 6 months after an acute stroke.[7] The case in this report still presented with constipation after acute phase, and there was fecaloma formation as a result of poorly management for chronic constipation.
In general, several mechanisms are identified that will affect the defecation, including aging, pelvic floor dysfunction, decreased mobility, and altered dietary intake. In our case, the long-term bedridden status due to old CVA combined with the elderly may be the most possibility that contributed to chronic constipation. However, in terms of stroke, the mechanism is multifactorial, so-called the brain–gut axis, including the central nervous system, enteric nervous system, autonomic nervous system, certain hormones, and luminal contents.[2],[3] After stoke, the injury of axis impairs the coordination of the peristaltic wave and rectal sensation, resulting in increasing rectal volume capacity. This not only leads to constipation but also bothers patients' quality of life.[8],[9]
Constipation leads to large stool volume and even development of fecaloma. Various manifestations are presented, such as bowel obstruction, urinary retention, and toxic megacolon.[10] Few case reports have described the relationship between constipation and ureteral obstruction with acute renal failure.[5] The mass effect of fecaloma would compress the ureters and make different levels of obstruction. In our patient, UTI was noted that drove us to treat it with empirical antibiotics and hydration with laxatives for constipation, but simple UTI was not enough to explain the AKI and hydronephrosis until large fecaloma was found.
The fecaloma could be managed conservatively with laxatives, enemas, or digital disimpaction, rectosigmoidal lavage through rectal tubes with manual manipulation,[10],[11] sometimes needed surgical intervention such as Hartmann procedure.[12] We used colonoscopy to irrigate the fecaloma of our patient. Fortunately, the AKI with bilateral hydronephrosis in our case was reversible after fecal disimpaction. It is proven that her ureters were compressed by fecaloma.
In the literatures, young children are susceptible to ureteral obstruction caused by fecal impaction due to the relative location of infant bladder and rectosigmoid, while the female's uterus prevented the ureter from direct compression of the fecal impaction.[11] However, fecaloma could still cause retroperitoneal ureters' obstruction, just like our case.
We present this case not only to emphasize the severity of constipation and associated complication that will develop if not properly dealed with. Besides, early recognition of the reversible etiology of AKI like the ureters obstructed by the fecaloma is also important. For patients who have a risk of constipation, adequate bowel program may be taken to relieve the symptoms and prevent the complication. Besides, we also want to emphasize that, as a neurosurgeon, we should pay attention to patients with long-term bed ridden after experiencing cerebral injury to avoid the complication, such as fecaloma formation, UTI, and bilateral hydronephrosis.
Acknowledgment
The author would like to acknowledge the assistance of Jinn-Rung Kuo, MD, Ph.D., Yongkang District, Tainan City, Taiwan, in the editing and submission process.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Vazquez Roque M, Bouras EP. Epidemiology and management of chronic constipation in elderly patients. Clin Interv Aging 2015;10:919-30.  |
| 2. | Hollerbach S, Kamath MV, Lock G, Schölmerich J, Upton AR, Tougas G. Assessment of afferent gut-brain function using cerebral evoked responses to esophageal stimulation. Z Gastroenterol 1998;36:313-24. |
| 3. | Karakuła-Juchnowicz H, Dzikowski M, Pelczarska A, Dzikowska I, Juchnowicz D. The brain-gut axis dysfunctions and hypersensitivity to food antigens in the etiopathogenesis of schizophrenia. Psychiatr Pol 2016;50:747-60. |
| 4. | Chute DJ, Cox J, Archer ME, Bready RJ, Reiber K. Spontaneous rupture of urinary bladder associated with massive fecal impaction (fecaloma). Am J Forensic Med Pathol 2009;30:280-3. |
| 5. | Gonzalez F. Obstructive uropathy caused by fecal impaction: Report of 2 cases and discussion. Am J Hosp Palliat Care 2010;27:557-9. |
| 6. | Downs J, Wolfe T, Walker H. Development of hydronephrosis secondary to poorly managed neurogenic bowel requiring surgical disimpaction in a patient with spinal cord injury: A case report. J Spinal Cord Med 2014;37:795-8. |
| 7. | Li J, Yuan M, Liu Y, Zhao Y, Wang J, Guo W. Incidence of constipation in stroke patients: A systematic review and meta-analysis. Medicine (Baltimore) 2017;96:e7225. |
| 8. | Ullman T, Reding M. Gastrointestinal dysfunction in stroke. Semin Neurol 1996;16:269-75. |
| 9. | Engler TM, Dourado CC, Amâncio TG, Farage L, de Mello PA, Padula MP. Stroke: Bowel dysfunction in patients admitted for rehabilitation. Open Nurs J 2014;8:43-7. |
| 10. | Ghosh G, Shah S, Maltz C. A Case of a Giant Fecaloma. Clin Gastroenterol Hepatol 2018;16:e48. |
| 11. | Nelson RP, Brugh R. Bilateral ureteral obstruction secondary to massive fecal impaction. Urology 1980;16:403-6. |
| 12. | Studer AS, Lonergan AM, Le Guillan S. Megabowel and Giant Fecaloma: A Surgical Condition? J Gastrointest Surg 2019;23:1269-70. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1]
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