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Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To describe and update stercoral colitis clinical risk factors, relative frequency, location, and CT imaging features correlated with surgical and pathological results., Methods: CT reports over a 5-year period (05/2017-05/2022) at a single medical center were searched. Main inclusion criteria were luminal distention with formed stool, wall thickening, and surrounding inflammation. Positive cases were graded as mild (early or developing stercoral colitis) versus moderate-to-severe based on CT findings. Medical records were reviewed for risk factors and outcome data in moderate-to-severe cases. P-values were tabulated for comparison., Results: 545 total cases (71 (60, 82) years, 278 males) were identified on CT, including 452 mild (82.9%) and 93 moderate-to-severe cases (17%, 67 (55, 79) years, 48 females). Twenty cases showed evidence of perforation (3.7% total cohort, 22% moderate-to-severe cohort). Diagnosis as an incidental finding was frequent (46.0% of mild cases). Most cases involved the rectum (97.6% of mild cohort and 69% of moderate-to-severe cohort). The sigmoid was involved in 31% of moderate-to-severe cases, but 95% of the perforated subcohort (19/20, 13/20 without rectal involvement). Among the moderate-to-severe cohort, perforation was associated with slightly increased wall thickness (6.4 vs. 5.7 mm, p = 0.03), opioid use (50 vs. 23%, p = 0.04), and disease-specific mortality (11 vs. 0%, p =0.04). Perforation was less associated with major neurocognitive disorders (20 vs. 60%, p = 0.003), institutionalized status (5 vs. 38%, p = 0.005), and a prescribed bowel regimen (30 vs. 63%, p = 0.01)., Conclusion: Stercoral colitis may be under-reported. Perforation tends to favor sigmoid involvement and a less traditional patient cohort., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Obstruction of the colon caused by a fecalith is not a rare condition, but endoscopic attempts at removal of the fecalith are often unsuccessful because of the size of the fecalith and its extremely hard stone-like consistency. We report a case of bowel obstruction of over two weeks' duration caused by a giant colonic fecalith. Conservative treatments including insertion of a gastric tube and enemas failed to resolve the obstruction. After an initial unsuccessful attempt at fecalith removal by colonoscopy using a snare, we successfully resolved the bowel obstruction over the course of subsequent colonoscopies with endoscopic fenestration of the fecalith and placement of a transrectal gastric tube for directed instillation of the enema fluid, and we were able to avoid surgical intervention in this case., Competing Interests: The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Few studies have evaluated the efficacy of ultrasonography (US) and abdominal radiography in assessing bladder and bowel dysfunction in children aged <24 months. We aimed to investigate the association between the risk of urinary tract infection (UTI) recurrence and fecal impaction using imaging findings., Methods: The medical records of 121 children (aged <24 months) with initial febrile UTI (fUTI) who were admitted to the authors' institution from January 2004 to September 2019 were reviewed retrospectively. We evaluated the rectal diameters of children with suspected fecal impaction that were measured using transabdominal US, or the rectal diameters divided by the distance between the ischial spines that were measured using abdominal radiography. Based on previous reports, we defined fecal impaction as a transabdominal US score of >30 mm or an abdominal radiography score of >0.5. The definition of functional constipation was based on the child/adolescent Rome IV criteria - i.e., a maximum stool frequency of twice per week., Results: The median age at initial fUTI diagnosis was 4 months. The occurrence of fecal impaction identified via imaging was significantly greater in patients with UTI recurrence than in those without recurrence: yes/no: 17/9 (65.4%) versus 35/60 (36.8%); P = 0.013. On the other hand, the occurrence rates of constipation based on stool frequency did not differ between the two groups. In multiple logistic analyses, fecal impaction detected via imaging was identified as an independent risk factor for fUTI recurrence., Conclusions: Fecal impaction observed via US and abdominal radiography may be useful in predicting the recurrence of fUTI in children., (© 2022 Japan Pediatric Society.)

Fecalith is a concretion of dry compact feces or hard stony mass of faeces in the intestinal tract. Though appendicular fecoliths are commonly encountered, caecal fecoliths are rare entities. Fecoliths are amenable to conservative management with laxatives and enemas but surgical management prevents recurrence. We present a case of 27 years old male who was diagnosed with acute appendicitis with peritonitis. He was intraoperatively diagnosed as gangrenous and perforated retrocaecal appendix with multiple small fecaliths and a large fecalith on cecum with perforation. Appendectomy and primary repair of caecal perforation done. Histological examination of perforated margin confirmed as an inflammatory lesion.

Background: Fecal impaction (FI) is defined as a large mass of stool in the rectum and/or colon that is unable to be evacuated. No study to date details demographics and outcomes in a sizeable sample of FI patients in the USA., Aims: The present study aims to develop knowledge of FI by reporting descriptive measures and outcomes of patients presenting to a US emergency department (ED) with FI., Methods: Medical charts coded with FI at Beth Israel Deaconess Medical Center from 2016 or 2017 were identified retrospectively. Patients diagnosed with FI in the ED or subsequent to direct hospital admission from the ED were included. Patient-specific demographics, visit-specific details, medical and medication histories, and hospital treatment and outcome measures were included in a database and analyzed., Results: Thirty-two patients (mean age of 72.9 years, 62.5% female) had a total of 42 ED visits with FI. Patients had an average of 8.7 diagnoses and 11.2 medications listed in their charts. 54.8% of patients were taking at least one commonly prescribed constipating medication. The median total length of stay for admitted patients was 3 days, with nearly 90% of the ED visits with FI requiring hospital admission. 40.6% of patients experienced serious FI-related morbidities, and 21.9% of patients with FI died in the hospital., Conclusion: Patients presenting with FI had high risk of morbidity and mortality, complex medical histories, and large numbers of active treatment regimens. Patients with FI should receive immediate treatment and close monitoring for morbidities and complications.

Eosinophilic esophagitis (EoE), a Th2-type allergic immune disorder characterized by an eosinophil-rich esophageal immune infiltrate, is often associated with food impaction (FI) in pediatric patients but the molecular mechanisms underlying the development of this complication are not well understood. We aim to identify molecular pathways involved in the development of FI. Due to large variations in disease presentation, our analysis was further geared to find markers capable of distinguishing EoE patients that are prone to develop food impactions and thus expand an established medical algorithm for EoE by developing a secondary analysis that allows for the identification of patients with food impactions as a distinct patient population. To this end, mRNA patterns from esophageal biopsies of pediatric EoE patients presenting with and without food impactions were compared and machine learning techniques were employed to establish a diagnostic probability score to identify patients with food impactions (EoE+FI). Our analysis showed that EoE patients with food impaction were indistinguishable from other EoE patients based on their tissue eosinophil count, serum IgE levels, or the mRNA transcriptome-based p(EoE). Irrespectively, an additional analysis loop of the medical algorithm was able to separate EoE+FI patients and a composite FI-score was established that identified such patients with a sensitivity of 93% and a specificity of 100%. The esophageal mRNA pattern of EoE+FI patients was typified by lower expression levels of mast cell markers and Th2 associated transcripts, such as FCERIB, CPA3, CCL2, IL4 , and IL5 . Furthermore, lower expression levels of regulators of esophageal motility ( NOS2 and HIF1A ) were detected in EoE+FI. The EoE+FI -specific mRNA pattern indicates that impaired motility may be one underlying factor for the development of food impactions in pediatric patients. The availability of improved diagnostic tools such as a medical algorithm for EoE subpopulations will have a direct impact on clinical practice because such strategies can identify molecular inflammatory characteristics of individual EoE patients, which, in turn, will facilitate the development of individualized therapeutic approaches that target the relevant pathways affected in each patient.

The assessment of constipation symptoms is based on history and physical examination. However, the experience is highly subjective perhaps explaining why palliative medicine doctors continue to use plain abdominal radiographs as part of routine assessment of constipation. Previous studies have demonstrated poor agreement between clinicians with this work in palliative care, limited further by disparity of clinicians' experience and training. The aim of this work was to explore whether there was less variation in the assessments of faecal shadowing made by more experienced clinicians compared to their less experienced colleagues. This pragmatic study was conducted across six palliative care services in Sydney (NSW, Australia). Doctors of varying clinical experience were asked to independently report their opinions of the amount of shadowing seen on 10 plain abdominal radiographs all taken from cancer patients who self-identified themselves as constipated. There were 46 doctors of varying clinical experience who participated including qualified specialists, doctors in specialist training and lastly, doctors in their second- and third post-graduate years. Poor agreement was seen between the faecal shadowing scores allocated by doctors of similar experience and training (Fleiss's kappa (FK): RMO 0.05; registrar 0.06; specialist 0.11). Further, when the levels of agreement between groups were considered, no statistically significant differences were observed. Although the doctors did not agree on the appearance of the film, the majority felt they were able to extrapolate patients' experiences from the radiograph's appearance. As it remains challenging in palliative care to objectively assess and diagnose constipation by history and imaging, uniform and objective assessment and diagnostic criteria are required. It is likely that any agreed criteria will include a combination of imaging and history. The results suggest the use of radiographs alone to diagnose and assess constipation in palliative care represents low value care.

Objectives: Guidelines on functional constipation recommend digital rectal examination (DRE) when constipation is doubtful or with a suspicion of organic etiology. The guidelines do not clarify if DRE is mandatory to diagnose impaction. This study aims to determine the frequency of impaction detectable only on DRE among children satisfying Rome III criteria without requiring DRE and also the inter-observer influences on impaction detection by DRE., Methods: Children between 6 months to 13 years of age, presenting with history suggestive of constipation were assessed. After excluding those with suspicion of organic etiology, those who needed DRE for diagnosis of constipation and those who do not satisfy Rome III criteria without DRE, the rest who satisfied Rome III criteria were assessed for impaction by palpable fecoliths or constipation-associated fecal incontinence. Those without such impaction were randomized to 2 examiners for DRE to diagnose impaction, in the absence of contraindications., Results: Two hundred and thirty-three children were assessed. One hundred and sixty-nine satisfied Rome III without needing DRE. Forty-eight (28.4%) had impaction detectable without DRE. Among the rest, 28 (30.1%) had impaction by DRE. There was no difference between the frequency of impaction detected by the 2 examiners. Clinical characteristics were similar (P > 0.05) between those with impaction detectable by DRE and those without., Conclusions: DRE does detect cases of impaction not discernible by other means. Such a finding may be comparable between examiners. These children may be identified by other clinical characteristics. The clinical significance of such a finding needs more understanding from the standpoint of therapeutic choices.

Introduction: We present a first description of faecal impaction (FI) causing occlusion of the pelvic venous system, resulting in a bilateral thrombosis of the external iliac vein., Patients and Methods: Our 76-year-old female patient was admitted with gradual swelling of both legs. Clinical evaluation revealed a painless abdominal distension and marked bilateral edema of the legs. A computed tomography (CT) scan showed gross dilatation of the colon and rectum, with FI. A short bilateral occlusion of the external iliac vein was seen, with thrombus in both pelvic veins. Doppler ultrasonography confirmed a thrombosis of the external iliac vein and common femoral vein on both sides., Results: A conservative treatment consisting of manual evacuation, enema, laxatives and systemic anticoagulation was successfully applied., Conclusions: FI represents a common - yet preventable - health problem, mainly in the elderly. This case illustrates a rare complication of FI if left untreated.

Background: Stercoral colitis is a rare inflammatory process involving the colonic wall secondary to fecal impaction with high morbidity and mortality; especially if complicated with ischemic colitis, stercoral ulcer formation and subsequent perforation. There are several case reports published on abdominal perforation resulting from stercoral colitis. However, stercoral colitis complicated by ischemic colitis is rare. The purpose of this case report is to describe the potential challenges in the diagnosis and management of stercoral colitis with ischemic colitis., Case Presentation: An 87 years old male with history of chronic constipation presents with severe abdominal pain to the emergency department. The patient was hemodynamically stable. On physical examination, the abdomen was mildly distended with moderate tenderness. Lab work was significant for leukocytosis and lactic acidosis. Abdominal CT scan revealed large amount of retained stool in the colon, bowel wall thickening and infiltration of peri-colonic fat, which were suggestive for stercoral colitis. Patient was started on IV fluids and antibiotics. He was given an enema, followed by laxative and manual disimpaction of stool. Colonoscopy was performed and biopsies were obtained. Tissue biopsy was significant for focal active colitis with regenerative glandular changes and neural hyperplasia., Conclusion: Elevated lactic acid level secondary to ischemia of the bowel wall with CT scan findings aid in establishing the diagnosis of stercoral colitis complicated with ischemic colitis. Urgent treatment with laxatives and fecal disimpaction is indicated to prevent perforation and peritonitis.

Objectives: Constipation is a common cause of abdominal pain in children presenting to the emergency department (ED). The objectives of this study were to determine the diagnostic evaluation undertaken for constipation and to assess the association of the evaluation with final ED disposition., Methods: A retrospective chart review of children presenting to the pediatric ED of a quaternary care children's hospital with abdominal pain that received a soap suds enema therapy., Results: A total of 512 children were included, 270 (52.7%) were female, and the median age was 8.0 (IQR: 4.0-11.0). One hundred and thirty eight patients (27%) had a digital rectal exam (DRE), 120 (22.8%) had bloodwork performed, 218 (43%) had urinalysis obtained, 397 (77.5%) had abdominal radiographs, 120 (23.4%) had abdominal ultrasounds, and 18 (3.5%) had computed tomography scans. Children who had a DRE had a younger median age (6.0, IQR: 3.0-9.25 vs. 8.0, IQR: 4.0-12.0; p<0.001) and were significantly less likely to have radiologic imaging (OR=0.50, 95% CI 0.32-0.78; p=0.002), but did not have an increased odds of being discharged home. After adjusting for gender, ethnicity, and significant past medical history those with an abdominal radiograph were less likely to be discharged to home (aOR=0.56, 95% CI 0.31-1.01; p=0.05)., Conclusions: The diagnostic evaluation of children diagnosed with fecal impaction in the ED varied. Abdominal imaging may be avoided if children receive a DRE. When children presenting to the ED with abdominal pain had an abdominal radiograph, they were more likely to be admitted., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: To assess the usefulness of rectal diameter measurement on ultrasonography as a diagnostic tool for fecal retention in children., Methods: One hundred children (median age, 5.0 years), consisting of 80 with functional constipation and 20 without constipation, participated in the study. All patients underwent physical examination that included digital rectal examination. Forty-five children underwent ultrasonography in three differential planes: transection above the symphysis; under the ischial spine; and at the bladder neck. The measurement of the rectal diameter at the transection above the symphysis could most easily detect fecal retention and had the closest correlations with retention among the three planes., Results: Rectal diameter was wider at all measuring points (35.2 vs 20.9 mm above the symphysis, P < 0.0001; 35.7 vs 24.0 mm under the ischial spine, P < 0.0001; and 19.4 vs 8.7 mm at the bladder neck, P < 0.0001) in children with fecal retention than in those with no fecal retention. With regard to presence of constipation, children with fecal retention had a wider rectal diameter above the symphysis than those with no fecal retention (children with functional constipation, 35.3 vs 20.0 mm, P < 0.0001; children without constipation: 32.6 vs 14.6 mm, P = 0.0026). The cut-off for the rectal diameter measured above the symphysis to identify fecal retention was 27 mm, with high sensitivity and specificity (95.5% and 94.1%, respectively)., Conclusion: Ultrasound rectal diameter measurement can be used to detect fecal retention in children., (© 2016 Japan Pediatric Society.)

Background: Faecal impaction (FI) is a common problem in old people living in nursing home. Its prevalence and associated factors remain unknown in the general population., Aim: To evaluate FI prevalence in the Spanish population older than 65 years and to assess the factors associated with it., Methods: A telephone survey was carried out of a Spanish population older than 65 years random sample (N = 1000). FI was assessed using a previously validated questionnaire., Results: A total of 28,128 calls were made; 1,431 subjects were eligible and 1,000 subjects were enrollled, mean aged 74.6 ± 7.3 (65–97); 57.5% were women. At least 53 people reported FI within the past year (5.3% (CI 95%: 3.9–6.7%)). Only 0.03% met criteria for chronic constipation and faecal incontinence. FI-associated factors were constipation, female gender, reduced physical activity, and chronic renal failure (CRF)., Conclusion: FI is a prevalent problem in old Spanish population. Constipation and female gender are the main associated factors; low physical activity and CRF appear to play also a significant role. Further studies are required to confirm this association.

Faecal impaction is a problem which is becoming more prevalent now that the number of elderly patients is increasing. When not detected and treated inadequately, it can lead to symptoms such as diarrhoea, faecal incontinence and other serious problems like anorexia, vomiting and rectal ulcers with bleeding or even a bowel perforation. We describe two patients with serious and less common complications of faecolithiasis. Patient A, a 79-year-old woman with signs of dementia, presented with faecal incontinence and unexplained worsening of her cognitive symptoms leading to a situation where she could no longer live in her own home. Patient B, a 52-year-old woman, presented with urinary retention, stomach ache and constipation, suggesting an obstructive tumour in the pelvis. In both patients a CT-scan showed no pathology. Neither of the patients responded to oral laxative treatment. Eventually, a faecolith was detected and treated through endoscopic inspection and fragmentation. Both patients recovered completely.

Background: Functional gastrointestinal disorders (FGIDs) are chronic or recurrent gastrointestinal symptoms without structural or biochemical abnormalities. FGIDs are multifactorial conditions with different pathophysiologic mechanisms including altered motility, visceral hyperalgesia, brain-gut disturbance, genetic, environmental and psychological factors. Although in most cases gastrointestinal symptoms are transient and with spontaneous resolution in infancy multiple dietary changes and pharmacological therapy are often started despite a lack of evidence-based data. Our aim was to update and critically review the current literature to assess the effects and the clinical appropriateness of drug treatment in early (occurring in infants and toddlers) FGIDs., Methods: We systematically searched the Medline and GIMBE (Italian Group on Medicine Based on Evidence) databases, according to the methodology of the Critically Appraised Topics (CATs). We included reviews, clinical studies, and evidence-based guidelines reporting on pharmacological treatments. Systematic reviews and randomized controlled trials (RCTs) concerning pharmacologic therapies in children with early FGIDs were included, and data were extracted on participants, interventions, and outcomes., Results: We found no evidence-based guidelines or systematic reviews about the utility of pharmacological therapy in functional regurgitation, infant colic and functional diarrhea. In case of regurgitation associated with marked distress, some evidences support a short trial with alginate when other non pharmacological approach failed (stepped-care approach). In constipated infants younger than 6 months of age Lactulose is recommended, whilst in older ages Polyethylene glycol (PEG) represents the first-line therapy both for fecal disimpaction and maintenance therapy of constipation. Conversely, no evidence supports the use of laxatives for dyschezia. Furthermore, we found no RCTs regarding the pharmacological treatment of cyclic vomiting syndrome, but retrospective studies showed a high percentage of clinical response using cyproheptadine, propanolol and pizotifen., Conclusion: There is some evidence that a pharmacological intervention is necessary for rectal disimpaction in childhood constipation and that PEG is the first line therapy. In contrast, for the other early FGIDs there is a lack of well-designed high-quality RCTs and no evidence on the use of pharmacological therapy was found.

Unlabelled: Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity characterized by variable associations of headaches, encephalopathy, seizures, vomiting, visual disturbance, and focal neurological signs. Neuroimaging shows cerebral edema of different patterns, classically involving the parieto-occipital white matter. PRES has been associated with several conditions predominantly hypertension, eclampsia, and immunosuppressive therapy. However, constipation has not been previously described in association with the development of PRES. In this report, we describe an 11-year-old child with history of severe functional constipation who developed PRES, as a consequence of renovascular hypertension from severe fecal impaction. Both hypertension and neurologic dysfunction resolved after resolution of fecal impaction., Conclusion: Severe functional constipation is a previously unrecognized cause of severe acute hypertension, resulting in life-threatening neurologic dysfunction. We highlight this unrecognized complication of severe functional constipation with fecal impaction that is potentially preventable if managed appropriately.

Background: Fecal impaction (FI) is a common problem in the elderly and other at-risk groups, such as patients with a neuro-psychiatric disease. It has been associated with medical problems and high morbi-mortality. A systematic review of this topic might be useful to improve the knowledge in this area and helpful to make an appropriate and early diagnosis., Methods: A PubMed systematic search was performed using relevant keywords. Case reports published in English, Spanish or French till June 2014 were included if they had a diagnosis of FI and a medical complication secondary to it. Each case was classified based on its principal complication. The main objective is to create a classification of FI complications based on published clinical cases., Results: 188 articles met inclusion criteria, comprising 280 clinical cases. Out of the total, 43,5% were over 65 years old, 49% suffered from chronic constipation, 29% had an underlying neuropsychiatric disease and 15% were hospitalised or institutionalised. A total of 346 medical complications secondary to FI were collected. They were divided according to gastrointestinal tract involvement and then classified based on their anatomical and pathophysiological mechanism into three groups: Complications secondary to fecaloma effect on the intestinal wall (73.4%), on the intestinal lumen (14%) and on adjacent structures (12.6%)., Conclusions: FI causes complications that might be fatal. The elderly, underlying neuropsychiatric disease and hospitalised or institutionalised patients integrate the high-risk group in which FI must be suspected. The first FI complications classification is presented to improve the knowledge about this entity.

Background: Little is known about how obstructive defecation and colonic inertia symptoms contribute to constipation-related quality of life., Objective: We sought to characterize the differences in quality of life in patients with severe obstructive defecation and colonic inertia symptoms., Design: This study was a cross-sectional analysis of a prospective database., Setting: Patients were enrolled at a single tertiary referral center., Patients: We included consecutive adults with severe symptoms of obstructive defecation (n = 115) or colonic inertia (n = 90) as measured by the Constipation Severity Instrument., Main Outcome Measures: The primary outcomes measured were the Pelvic Floor Distress Inventory, Constipation-Related Quality of Life instrument, Pelvic Floor Impact Questionnaire, and 12-item Short Form Health Survey., Results: Although physical examination and anorectal physiology testing were similar between groups, patients with severe obstructive defecation symptoms reported worse pain, distress, and constipation-specific quality of life than patients with severe colonic inertia symptoms (all p < 0.001). Specifically, patients with severe obstructive defecation symptoms showed greater quality-of-life impairment related to eating, bathroom habits, and social functioning (all p ≤ 0.01). Furthermore, patients with severe obstructive defecation symptoms had inferior global quality of life on the 12-item Short Form Health Survey physical component score (p = 0.03) and mental component score (p = 0.06)., Limitations: The use of patient self-report instruments resulted in a proportion of patients with incomplete data., Conclusion: Quality of life was impaired in both groups of patients; however, patients with severe obstructive defecation symptoms were affected to a significantly greater extent. The fact that there were no differences in objective findings on physical examination or anorectal physiology studies highlights the importance of assessing quality of life during the evaluation and treatment of constipated patients.

Chronic constipation is a very common complaint at outpatient clinics. It can progress to fecal impaction, and rarely to fecalomas if not managed promptly. Fecaloma is characterized by a hardened large mass of feces frequently localized in sigmoid colon and rectum and is difficult to discharge. Fecaliths, stagnating and hardening by time, may cause intestinal obstruction,ulcer development and colonic wall perforation. We present the case of a 24-year-old woman who admitted to our hospital with complaints of severe constipation with 1 bowel movement every third-fifth day with passage of hard stools only with using laxatives and meteorism. This is a rare case of fecalomas and megacolon, when conservative measures were absolutely ineffective and surgical treatment was needed. Therefore, diagnosis of fecaloma must be considered in patients presenting with chronic constipation and abdominal mass.Further investigations are mandatory to delineate guidelines for clinical management of megacolon especially in women of childbearing age.

The presence of an appendiceal fecalith should not be considered as a categorical sign of acute appendicitis. The fecalith may, however, be responsible for abdominal pain--right lower quadrant tenderness without associated appendicitis, i.e. appendiceal colic. When a patient presents with right lower quadrant abdominal tenderness, abdomino-pelvic computerized tomography (CT) may establish this diagnosis by demonstrating the presence of the appendicolith but without evidence of appendiceal inflammation or infection. Spontaneous migration of the appendicolith may result in cure. In this previously unpublished clinical case, the CT demonstrates the spontaneous passage of the appendicolith, which coincided in time with the resolution of the abdominal pain syndrome. When a patient presents with typical symptoms of appendiceal colic and CT findings of an appendicolith without appendicitis, appendectomy will certainly relieve the pain. But if the stone passes spontaneously, the need for appendectomy is debatable, particularly in a high-risk patient., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Fecal impaction (FI) is a common and potentially serious medical condition that occurs in all age groups. Children, incapacitated patients, and the institutionalized elderly are considered the highest at-risk populations. FI usually occurs in the setting of chronic or severe constipation, anatomic anorectal abnormalities, and neurogenic or functional gastrointestinal disorders. Generally, FI is a preventable disorder, and early recognition is important, as it is associated with increased morbidity, mortality, and high health care costs. Evaluation with a careful history and physical examination, in conjunction with radiologic imaging, such as an acute abdominal series or computed tomography (CT), is imperative. Prompt identification and treatment minimize the risk of complications attributable to FI, which may include bowel obstruction leading to stercoral ulcer, perforation, peritonitis, or cardiopulmonary collapse with hemodynamic instability. Treatment options include manual fragmentation and extraction of the fecal mass, distal colonic cleansing using enemas and rectal lavage with the aid of a sigmoidoscope, and/or using water-soluble contrast media such as Gastrografin to both identify the extent of the impaction and aid in cleansing and removal. Surgical resection of the involved colon or rectum is reserved for peritonitis resulting from bowel perforation. Since recurrence is common, implementing preventive measures such as increasing daily water and fiber intake, limiting medications that decrease colonic motility, using secretagogues or prokinetic agents, and treating underlying anatomic defects are highly important.

Background: There are no existing studies that provide data regarding the epidemiology of, and risk factors for, fecal impaction, either in the general population or in any sub-group of people., Objective: Estimate the prevalence of and factors associated with fecal impaction on a representative sample of the institutionalized elderly population., Design: Two-phase study. Phase 1: pilot study validating the methodology in which all residents of a single nursing home participated. Phase 2: national multi-center cross-sectional study., Setting: 34 randomly selected nursing homes., Measurements: The presence of fecal impaction and associated factors were evaluated using three different tools: data collected from medical records; a self-completion questionnaire filled out by the subjects or a proxy; and a rectal examination., Subjects: Older subjects living in nursing homes., Results: The prevalence of chronic constipation was 70.7% (95%CI: 67.3-74.1%), of which 95.9% of patients were properly diagnosed and 43.1% were properly controlled. The prevalence of FI according to patient history was 47.3% (43.6-51.0%) and 6.6% (4.7-8.5%) according to rectal examination. Controlled constipation (OR: 9.8 [5.2-18.4]) and uncontrolled constipation (OR: 37.21 [19.7-70.1]), the number of medications (OR: 1.2 [1.1-1.3]), reduced functional capacity (OR: 0.98 [0.97-0.99]) and the occasional use of NSAIDs were independent risk factors for fecal impaction., Conclusions: Constipation affects more than 70% of people living in nursing homes. Although it is properly diagnosed in more than 95% of cases, the disease is only controlled in less than 50%. Constipation, especially when not controlled, is the most significant risk factor leading to fecal impaction, which is prevalent in almost 50% of this population.

A 60-year-old woman presented to the accident and emergency department with a 3-day history of lower abdominal pain, which was sudden in onset, localised to the right iliac fossa, constant and aggravated by movements. On examination, she was febrile (100 · F), tachycardic and normotensive. Examination of the abdomen revealed an ill-defined tender mass in the right iliac fossa. A clinical diagnosis of appendicular mass was made and treated conservatively. After a few days the mass became smaller, firmer, mobile and non-tender. Since the mass persisted, the patient was investigated further to rule out carcinoma of the caecum. A contrast-enhanced CT (CECT) of the abdomen showed a mass with air pockets in the caecum, suggestive of caecal faecolith. After 6 weeks, appendicectomy and removal of the faecolith were performed. The postoperative period was uneventful. Histopathology of the appendix showed inflammatory changes confirming appendicitis.

Background: Large colon impactions are a common cause of colic in the horse. There are no scientific reports on the clinical presentation, diagnostic tests and treatments used in first opinion practice for large colon impaction cases. The aim of this study was to describe the presentation, diagnostic approach and treatment at the primary assessment of horses with large colon impactions., Methods: Data were collected prospectively from veterinary practitioners on the primary assessment of equine colic cases over a 12 month period. Inclusion criteria were a diagnosis of primary large colon impaction and positive findings on rectal examination. Data recorded for each case included history, signalment, clinical and diagnostic findings, treatment on primary assessment and final case outcome. Case outcomes were categorised into three groups: simple medical (resolved with single treatment), complicated medical (resolved with multiple medical treatments) and critical (required surgery, were euthanased or died). Univariable analysis using one-way ANOVA and Tukey's post-hoc test, Kruskal Wallis with Dunn's post-hoc test and Chi squared analysis were used to compare between different outcome categories., Results: 1032 colic cases were submitted by veterinary practitioners: 120 cases met the inclusion criteria for large colon impaction. Fifty three percent of cases were categorised as simple medical, 36.6% as complicated medical, and 9.2% as critical. Most cases (42.1%) occurred during the winter. Fifty nine percent of horses had had a recent change in management, 43% of horses were not ridden, and 12.5% had a recent / current musculoskeletal injury. Mean heart rate was 43 bpm (range 26-88) and most cases showed mild signs of pain (67.5%) and reduced gut sounds (76%). Heart rate was significantly increased and gut sounds significantly decreased in critical compared to simple medical cases (p<0.05). Fifty different treatment combinations were used, with NSAIDs (93%) and oral fluids (71%) being administered most often., Conclusions: Large colon impactions typically presented with mild signs of colic; heart rate and gut sounds were the most useful parameters to distinguish between simple and critical cases at the primary assessment. The findings of seasonal incidence and associated management factors are consistent with other studies. Veterinary practitioners currently use a wide range of different treatment combinations for large colon impactions.

Background: Studies on the epidemiology of fecal impaction are limited by the absence of a valid and reliable instrument to identify the condition in the elderly. Our aim is to validate a questionnaire for identifying fecal impaction in the elderly and to assess the impact of cognitive impairment and the aid of a proxy on its reliability., Methods: We developed a 5 questions' questionnaire. The questionnaire was presented to twenty doctors to test its face validity. Feasibility was pre-tested with ten non institutionalized subjects who completed the questionnaire twice, once alone or with the help of a proxy, and another along with the researcher.For the validation of the questionnaire all residents in a single nursing-home were invited to participate, allowing the self-decision of using a proxy. Medical records of all subjects were abstracted without knowledge of subjects' answers and agreement between fecal impaction according to self-reported and medical records analyzed. Physical impairment was measured with the Barthel's test and cognitive impairment with the mini-mental test., Results: In the face validity only minor changes in wording were suggested. In the feasibility pre-test all subjects were able to understand and complete the questionnaire and all questions were considered appropriate and easily understandable.One-hundred and ninety-nine of the 244 residents participated in the study (mean age 86,1 ± 6,6). One hundred and forty two subjects understood all questions; not understanding them was inversely associated with cognitive impairment score (aOR: 0.86; 95% CI: 0.82-0.91). One hundred and sixty decided to use a proxy; the use of a proxy was inversely associated with educative level (0.13 (0.02-0.72), minimental's score (0.85; 0.76-0.95) and Barthel's score (0.96; 0.94-0.99). Agreement between medical records and self-completed questionnaire was 85.9% (kappa 0.72 (0,62- 0,82). Disagreement was unrelated to education and cognitive impairment., Conclusions: Our simple questionnaire is reliable for identifying fecal impaction in the elderly by self-report. Limitation imposed by cognitive impairment is minimized with the aid of a proxy.

Background: Obstructed defecation syndrome is a widespread and disabling disease., Objective: We aim to evaluate the safety and efficacy of stapled transanal rectal resection performed with a new dedicated curved device in the treatment of obstructed defecation syndrome., Design: A retrospective review of 187 stapled transanal rectal resections performed from June 2007 to February 2011 was conducted., Settings: The entire study was conducted at a university hospital., Patients: : All the patients with symptomatic obstructed defecation syndrome and the presence of a rectocele and/or a rectorectal or rectoanal intussusception, in the absence of sphincter contractile deficiency, were included in the treatment protocol., Interventions: All procedures were performed with the use of the Contour Transtar device. We analyzed the functional results of this technique, the incidence and features of the surgical and functional complications, and ways to prevent or treat them., Main Outcome Measures: Constipation was graded by using the Agachan-Wexner constipation score; use of aids to defecate and patient satisfaction were assessed preoperatively and 6 months after surgery. Intraoperative and postoperative complications were also investigated., Results: The constipation intensity was statistically reduced from the preoperative mean value of 15.8 (± 4.9) to 5.2 (± 3.9) at 6 months after surgery (p < 0.0001). Of the 151 (80.3%) patients who took laxatives and the 49 (26.2%) who used enemas before treatment, only 25 (13.2%; p < 0.0001) and 7 (3.7%; p < 0.0001) continued to do so after surgery. None of the 17 (9.1%) patients who had previously helped themselves with digitations needed to continue this practice. Almost all patients showed a good satisfaction rate (3.87/5) after the procedure., Limitations: Limitations are the short follow-up of 1 year and the design of the study that may introduce potential selection bias., Conclusions: The results of this study show that stapled transanal rectal resection performed with the use of the Contour Transtar is a safe and effective procedure to treat obstructed defecation syndrome.

Background: Surgery is indicated for chronic constipation refractory to conservative therapy. The treatment of combined slow-transit constipation and obstructive defecation is controversial., Objective: The aim of the study is to describe the Jinling procedure and examine safety, effectiveness, and quality of life over 4 years of follow-up., Design: The study is a retrospective review of prospectively gathered data in a patient registry database., Settings: This investigation was conducted at a tertiary-care gastroenterology surgical center in China., Patients: The study included 117 consecutive patients with slow-transit constipation combined with obstructive defecation treated between January 2005 and December 2007., Intervention: The Jinling procedure modifies the classic procedure of subtotal colectomy with colorectal anastomosis by adding a new side-to-side cecorectal anastomosis to solve the coexistence of obstructive defecation and slow-transit constipation in one operation., Main Outcome Measures: We measured morbidity and mortality rates, Wexner constipation scores, and Gastrointestinal Quality of Life Index at baseline and after 1, 6, 12, 24, 36 and 48 months of follow-up., Results: A total of 117 patients underwent the Jinling procedure, which was laparoscopically assisted in 56 patients (47.9%) and an open procedure in 61 patients (52.1%). Of the total, 72 patients (61.5%) had undergone previous surgical intervention without improvement. A total of 28 complications and adverse events were reported in 117 procedures, giving an overall morbidity rate of 23.9%; 23 patients (19.7%) had 1 or more events. Most complications were managed conservatively. A significant reduction in Wexner constipation score was observed from baseline (mean, 21.9) to 1 month (mean, 9.8), and the reduction was maintained at 48 months (mean 5.1; p < 0.001). Compared with baseline, significant overall improvements were also seen in gastrointestinal quality of life at 12, 24, and 48 months of follow-up (p < 0.01)., Limitations: This study did not include a comparison group., Conclusions: Our clinical practice demonstrates that Jinling procedure is safe and effective for refractory slow-transit constipation associated with obstructive defecation, with minimal major complications, significant improvement of quality of life, and a high satisfaction rate after 4-year follow up.