A Case of Fecal Impaction in a Young Male After Mismanaged Diarrhea

Case at a Glance

A 27-year-old male presented with symptoms of fecal impaction, including severe tenesmus, following a two-week course of self-managed alternating diarrhea and constipation, treated with loperamide and escalating doses of laxatives.

Patient's Story

The patient is a 27-year-old male with no significant past medical history who presented with a chief complaint of a severe sensation of rectal fullness and incomplete evacuation. The history began approximately two weeks prior with an episode of diarrhea and general stomach upset. Following a telehealth consultation, he began taking loperamide (Imodium). The diarrhea initially subsided, and he noted passing narrow-caliber stools. When the diarrhea recurred, he took another dose of loperamide. Subsequently, he developed constipation. Over the next week, he attempted to treat the constipation with an escalating regimen of laxatives. He first took two senna-based laxative pills (Prunelax), which induced a bowel movement but left him with a persistent feeling of incomplete evacuation. The next day, he took another pill, which worsened this sensation. Becoming more concerned, he consumed a bottle of magnesium citrate over a two-day period. This resulted in multiple episodes of liquid stool, during which he passed one small, hard, round piece of stool. Despite the profuse liquid diarrhea, the sensation of a rectal blockage intensified. In the 24 hours prior to presentation, he took two additional senna-based laxative pills, which only worsened his primary symptom, a distressing feeling he described as 'constantly holding in stool.'

Initial Assessment

The patient presented with significant distress due to the rectal symptoms but reported no abdominal pain, fever, nausea, or vomiting. His primary complaint was tenesmus—a constant and painful urge to defecate without the ability to pass stool. He appeared well-hydrated, having consciously increased his fluid intake with water and electrolyte beverages. An abdominal examination would likely reveal a soft, non-tender, non-distended abdomen with normal bowel sounds. The key diagnostic procedure would be a digital rectal exam (DRE), which would be expected to reveal a large, hard, non-mobile stool mass in the rectal vault, confirming a fecal impaction.

The Diagnostic Journey

The diagnosis was strongly suggested by the patient's history. The initial use of an anti-motility agent (loperamide) for diarrhea likely initiated the constipating process, leading to the formation of a hard stool mass. The subsequent passage of only liquid stool around this obstruction (overflow diarrhea) is a classic sign of impaction. His primary symptom of tenesmus could be caused by the mass itself or by secondary rectal irritation from the aggressive laxative use. The definitive diagnosis, however, would be clinical, based on the palpable findings of a large stool mass during a digital rectal exam. Given the clarity of the history and the expected physical exam findings, imaging studies like an abdominal X-ray would likely be unnecessary.

Final Diagnosis

Fecal Impaction with secondary tenesmus.

Treatment Plan

Given the size and density of the impaction suggested by the patient's history, home treatment with an enema was considered but deemed likely to fail. The recommended course of action would be a visit to an Urgent Care or Emergency Department (ED), with the ED being the more appropriate setting for the required procedure.

1. Manual Disimpaction: The primary treatment is manual fragmentation and removal of the impacted stool from the rectal vault. This procedure is performed in the ED.
2. Cleansing Enema: Following manual disimpaction, a mineral oil or tap water enema may be administered to help clear any remaining stool from the distal colon.
3. Bowel Regimen: To prevent recurrence, the patient would be started on an oral osmotic laxative, such as polyethylene glycol 3350, to soften stool and ensure complete evacuation over the following days.
4. Patient Education: A critical component of the plan involves counseling the patient on the risks of using anti-motility agents during episodes of diarrhea and the dangers of laxative overuse. Education would focus on dietary management (increased fiber and fluid intake), lifestyle changes (regular physical activity), and establishing a regular toileting routine to prevent future episodes.

Outcome and Follow-up

The patient would undergo successful manual disimpaction in the Emergency Department, resulting in immediate and significant relief of his symptoms. He would be discharged home with a prescription for polyethylene glycol and comprehensive instructions on diet, hydration, and bowel habits. A follow-up appointment with a primary care physician would be scheduled within 1-2 weeks to ensure the normalization of his bowel function and to discuss long-term preventative strategies. With adherence to the treatment plan, the patient is expected to make a full recovery without long-term complications.