Fecal Impaction: Not Always a Benign Condition: 1475

Fecal impaction (FI) is commonly seen in geriatric patients. Other high risk groups include those with neurological, renal, and psychiatric diseases. Psychiatric patients represent 27% of FI cases and are associated with higher morbidity. Common causes include medication, electrolyte imbalance, and dehydration. Complications include stercoral ulcers, intussusception, obstruction, and perforation. We present a case of a rare complication of FI. A 33-year-old schizophrenic male on risperidone presented to our ER from a nursing home with abdominal pain, fever, poor oral intake, weight loss, and diarrhea. He was hospitalized a month prior for constipation and urinary retention, which was relieved by magnesium citrate and foley placement. Upon this admission, he was tachycardic and febrile. His abdomen was tense, without bowel sounds, and a hard mass in the left lower quadrant was palpable. Labs showed a WBC=27.4K/UL, Cr=1.34md/dL, and lactate=3.2mmol/L. Urinalysis showed trace leukocyte esterase and 9 WBCs. CT scan revealed a distended bladder with bilateral hydronephrosis, left pyelonephritis, and stool with stercoral colitis. The distal colon was distended to 14cm. He was admitted to the MICU and started on broad spectrum antibiotics. Manual disimpaction was unsuccessful. He initially refused treatment, but his assigned health-care proxy agreed to only medical management. Hemicolectomy was planned, but cancelled due to ethical concerns. A repeat CT on hospital day 13 showed bilateral pyelonephritis and a left renal abscess. Antibiotics were narrowed to ciprofloxacin and metronidazole. He clinically improved and abscess shrinkage was noted on CT. After extensive discussions, he decided to follow up for an outpatient hemicolectomy. Obstructive uropathy and pyelonephritis have been rarely described as complications of FI. Based on a literature search of case reports, these complications are predominately seen in the elderly with 15 of the 19 described cases been in patients ≥65 years and only 2 cases requiring ICU admission. Among institutionalized adults, efforts to prevent FI include increasing the availability of toileting services. However, no specific prevention recommendations are available for psychiatric patients, who are at higher risk given the use of anticholinergic and antiserotonergic medications. Limited studies recommend osmotic laxatives and enemas in addition to diet and exercise for the prevention of FI and its complications.Figure 1Figure 2