A 76-year-old man is brought to the office for evaluation of fecal incontinence. The patient has a history of lung cancer metastatic to the bones and liver. He takes opiate analgesics with adequate pain control. The patient has become increasingly debilitated over the past 6 months and requires assistance with most activities of daily living. His caregiver notes that the patient has chronic constipation with 1 or 2 hard bowel movements per week, but over the past 2 days he has been incontinent of small volume soft stools. The patient has also been having mild nausea and decreased appetite but has had no fever, chills, vomiting, or dysuria. There is no visible blood or mucus in the stool. Temperature is 37 C (98.6 F), blood pressure is 116/74 mm Hg, and pulse is 86/min. Abdomen is distended but soft with mild diffuse tenderness and normal bowel sounds. Which of the following is the most appropriate next step in management of this patient?

Question

A 76-year-old man is brought to the office for evaluation of fecal incontinence.  The patient has a history of lung cancer metastatic to the bones and liver.  He takes opiate analgesics with adequate pain control.  The patient has become increasingly debilitated over the past 6 months and requires assistance with most activities of daily living.  His caregiver notes that the patient has chronic constipation with 1 or 2 hard bowel movements per week, but over the past 2 days he has been incontinent of small volume soft stools.  The patient has also been having mild nausea and decreased appetite but has had no fever, chills, vomiting, or dysuria.  There is no visible blood or mucus in the stool.  Temperature is 37 C (98.6 F), blood pressure is 116/74 mm Hg, and pulse is 86/min.  Abdomen is distended but soft with mild diffuse tenderness and normal bowel sounds.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d87c_3ba2_bc81_4945119e850d_MD0003_00 This elderly patient likely has overflow fecal incontinence due to fecal impaction. Fecal impaction is common in older patients with impaired mobility, inadequate fluid or dietary fiber intake, chronic constipation, or decreased sensation of stool in the rectal vault (eg, spinal cord injury, dementia). Obstruction of fecal flow in the rectum can cause backup of stool proximal to the impaction; passage of liquid stool around the impaction leads to incontinence. Urinary incontinence is also common due to pressure against the bladder. The diagnosis of fecal impaction is typically apparent on digital rectal examination, although impaction in the proximal rectum may be apparent only on abdominal x-ray. Initial management includes manual disimpaction to break up the hard stool followed by enemas (eg, tap water, mineral oil) to dislodge the fecal fragments. Following acute treatment, a bowel regimen, including laxatives (eg, polyethylene glycol, lactulose) and dietary alterations (eg, increased intake of fluid and fiber), should be instituted. (Choice A) Loperamide slows the transit of stool through the colon, reduces the water content of the stool, and is used for symptomatic management of diarrhea. However, the primary disorder in this patient is constipation (likely due to opiates); loperamide would likely worsen the impaction and result in paradoxical worsening of fecal incontinence. (Choice C) Plain x-ray is the most appropriate initial imaging study for fecal impaction, when necessary. CT scan is useful for evaluating extrinsic intestinal compression, but it is not usually needed and would not be the first study. (Choice D) Stool studies (eg, culture, microscopy for ova and parasites) are appropriate to evaluate for suspected infectious diarrhea, which presents with large-volume watery stools. This elderly patient with chronic constipation and incontinence of small stools is more likely to have fecal impaction with overflow incontinence. (Choice E) Anal manometry can provide information regarding anorectal neurologic dysfunction and is indicated for evaluation of chronic constipation and fecal incontinence. However, this patient's symptoms are likely attributable to known factors (ie, debilitation, opioid analgesics), and neurophysiologic studies are unlikely to add useful information. Disimpaction should be performed first. Educational objective: Fecal impaction is common in older patients with impaired mobility, chronic constipation, or decreased sensation of stool in the rectal vault. Obstruction of fecal flow in the rectum can cause backup of stool; passage of liquid stool around the impaction can lead to incontinence. Initial management includes manual disimpaction and enemas to clear the rectal vault.

A 76-Year-Old Man Is Brought to the Office for Evaluation