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Case 321

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A 20 year-old male patient with non-specified neuropsychomotor development retardation is admitted to the emergency department with respiratory distress, abdominal distension and a 4 week constipation history that did not resolve with home laxative measures. Interrupted flatus passage in the last 24 hours. Digital rectal examination identified a large fecaloma. After being submitted to complementary exams, the patient developed tachydyspnea (40 ripm), tachycardia (140 bpm), confusion and respiratory failure (SpO2 82% while breathing ambient air).

After careful consideration of the clinical scenario and imaging exams, what is the most appropriate management option for this patient?

a) Non-invasive ventilation followed by per os administration of 120 mL of lactulose solution or 500 mL of 80g polyethylene glycol solution.

25%

b) Face mask or nasal cannula oxygen therapy and immediate 12% glycerol enema followed by cathartic measures.

25%

c) General anesthesia with rapid sequence intubation, urgent left colectomy and Hartmann colostomy.

25%

d) Orotracheal intubation, manual fecal disimpaction under anesthesia and enema tube placement.

25%
   

Image analysis 

 

Image 1: Chest radiograph, AP view, patient in dorsal decubitus. Reduced inspiration probably due to abdominal distension. Non-specific consolidations in superior and lower right pulmonary lobes (red arrows) compatible with subsegmental atelectasis due to compression.

 

 

Image 2: Plain abdominal radiograph, AP view, patient in dorsal decubitus. Gaseous distension of the large bowel (blue arrows) with heterogeneous fecal content (yellow arrows).

 

 

Image 3: Non contrast-enhanced adbominal and pelvic computed tomography (CT) scan, coronal reconstruction at the level of coxofemoral articulations. Large bowel and rectum distension (blue arrows) with heterogeneous fecal content. Rectal wall thickening (in red).

Highlights

- Fecal impactation causes: severe constipation, anorectal anomalies, neurogenic and functional gastrointestinal dysfunction and bowel hypomotility;

- Clinical picture: abdominal distenstion, abdominal pain and interruption of flatus and stool passage;

- Imaging: large bowel dilatation with gaseous and fecal content;

- When faced with intestinal obstruction due to fecaloma: patient stabilization followed by manual disimpaction and enema tube positioning;

- Surgical treatment is indicated when response to clinical treatment is poor or when complications arise.

 References

- Emergências Clínicas: abordagem prática. Ed. Martins HS, Brandão Neto RA, Scalabrini Neto A. 11thedition: Manole, 2016.

- Sobrado, CW et al. Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria. J coloproctol (rio j). 2018;38(2):137–144. https://doi.org/10.1016/j.jcol.2018.02.003

- Serrano Falcón B, Barceló López M, Mateos Muñoz B, Álvarez Sánchez A, Rey E. Fecal impaction: a systematic review of its medical complications. BMC Geriatrics. 2016;16:4. doi:10.1186/s12877-015-0162-5.

- Klauser AG, Voderholzer WA, Heinrich CA, et al. Behavioral modification of colonic function. Can constipation be learned? Dig Dis Sci 1990;35:1271-75. 

- Wald A. UpToDate [Internet]. Uptodate.com. 2018 [cited 3 April 2018]. Available from: https://www.uptodate.com/contents/management-of-chronic-constipation-in-adults?search=Management%20of%20chronic%20constipation%20in%20adults&source=search_result&selectedTitle=1~150&usage_

type=default&display_rank=1

Author

Ariádna Andrade Saldanha da Silva, 6thyear medical student at UFMG

Mail: ariadna.andrade[at]hotmail.com

 

Bernardo Bahia Finotti, 6thyear medical student at UFMG

Mail: bernardofinotti[at]hotmail.com

Supervisor

Marco Antonio Gonçalves Rodrigues. Associate Professor of Surgery and Head of the Department of Surgery of the Faculty of Medicine of the Federal University of Minas Gerais. Coordinator of the Esophagus, Stomach and Duodenum Group of the Alpha Institute of Gastroenterology of Hospital das Clínicas da UFMG.

Mail: magro.mg[at]terra.com.br

 

Túlio Bernardino, Professor at the Department of Anatomy and Imaging of the Faculty of Medicine of the Federal University of Minas Gerais

Mail: itulio [at]gmail.com

 Reviewers

André Naback, Gabriel Santos, Elaine Iwayama, Mateus Nardelli, Professor José Nelson Mendes Vieira and Professor Viviane Santuari Parisotto Marino.

Translated by

Lucas Bruno Rezende, 6th year medical student at UFMG

Test question

[Emergency Hospital of Goiânia – adapted question] In a clinical scenario of acute obstructive abdomen, which of the following should be the first imaging exam ordered?

a) Plain abdominal radiographs

25%

b) Plain abdominal radiographs

25%

c) Abdominal ultrasound

25%

d) Barium enema

25%

e)

25%
   

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