Severe Fecal Impaction in a Young Adult Refractory to Standard Therapies

Case at a Glance

An 18-year-old female presented with a two-week history of obstipation and increasing abdominal pain, despite trying numerous over-the-counter laxatives. A CT scan confirmed significant fecal loading. The case highlights the need for an aggressive, multi-modal laxative approach when standard first-line treatments fail.

Patient's Story

The patient is an 18-year-old female with a known allergy to prunes who presented with a chief complaint of being unable to pass stool for approximately two weeks. The condition was associated with significant abdominal bloating, gas, and increasing abdominal pain. She reported straining without success during attempts to defecate. In an attempt to self-treat, she had tried an extensive list of remedies including psyllium fiber (Metamucil), polyethylene glycol 3350 (Miralax), sennosides (Ex-lax), glycerin suppositories, a Fleet enema, oral magnesium citrate, and dietary interventions such as coffee, increased fluids, dates, and yogurt. She also engaged in regular exercise and abdominal massage, all without effect. Her growing pain and distress prompted two separate visits to the Emergency Department (ED).

Initial Assessment

The patient was evaluated in the Emergency Department on two occasions. During the first visit, her symptoms were noted and she was advised to continue conservative measures and allow more time for them to work. As her pain worsened, she returned to a different ED. During this second visit, a CT scan of the abdomen and pelvis was performed. The imaging revealed a large stool burden, with significant fecal matter noted in the ascending and transverse colon, consistent with fecal impaction. An incidental finding of colonic diverticulosis without signs of acute diverticulitis was also reported. The patient was discharged with instructions to take Metamucil, which she had been using for four days post-visit without any relief.

The Diagnostic Journey

Despite a clear diagnosis of fecal impaction from the CT scan, the patient's primary challenge was treatment failure. The standard, sequential use of various classes of over-the-counter laxatives had proven ineffective. The bulking agent (Metamucil) recommended during her second ED visit may have been inappropriate for an established impaction, potentially worsening the bulk without providing sufficient hydration or motility to clear the blockage. The patient was facing a multi-week wait for a gastroenterology consultation and was becoming increasingly distressed. The case illustrates a common clinical crossroads where initial outpatient management is insufficient, requiring a more aggressive, protocol-driven approach typically reserved for inpatient settings or pre-procedural bowel preparation.

Final Diagnosis

1. Fecal Impaction secondary to Severe Constipation.
2. Incidental finding of Colonic Diverticulosis.

Treatment Plan

Given the failure of single-agent therapies and the significant stool burden, a more aggressive home-based bowel cleanout regimen was recommended, mirroring a colonoscopy preparation protocol.

1. Discontinuation of Bulking Agents: The patient was advised to stop taking Metamucil immediately to prevent adding more bulk to the impacted stool.

2. Aggressive Osmotic and Stimulant Laxative Protocol:

   • Cleanout Phase: A high-dose osmotic laxative regimen was initiated. The patient was instructed to mix 7 capfuls (approximately 119 grams) of Miralax (polyethylene glycol 3350) into 32 ounces of an electrolyte-containing beverage (e.g., Gatorade) and consume it over 4 hours. This was combined with a stimulant laxative, two tablets of sennosides (Ex-lax), taken before starting the Miralax solution and again after finishing if no bowel movement occurred.
   • Continuation: This process could be repeated up to two more times if a bowel movement was not achieved within 8 hours. The goal was to continue the regimen until the patient was passing near-liquid stool, indicating the impaction had cleared.

3. Maintenance Therapy: Once the initial cleanout was successful, the patient was to begin a long-term maintenance regimen to prevent recurrence and allow the distended colon to return to normal function. This included a daily dose of 1/2 to 1 capful of Miralax and one tablet of sennosides, to be titrated to achieve one soft, easily passed bowel movement daily. This regimen was recommended for at least 6 months.

4. Supportive Care: The patient was counseled on the importance of maintaining excellent hydration, especially during the cleanout phase.

Outcome and Follow-up

The patient initiated the aggressive cleanout protocol and experienced a significant bowel movement within 6 hours of finishing the first round of high-dose Miralax and sennosides. She continued the protocol for one more cycle to ensure complete evacuation. Her abdominal pain and bloating resolved. She was successfully transitioned to a daily maintenance dose of Miralax and a sennoside tablet. She was scheduled to keep her gastroenterology appointment to investigate the underlying cause of her severe chronic constipation and the unusual finding of diverticulosis in a patient of her age, with plans for a possible colonoscopy and motility studies.