Fecaloma causing small bowel obstruction in the absence of risk factors: a case report

Abstract

Background

Small bowel obstruction is a common surgical emergency typically caused by adhesions, hernias, and malignancies. However, ileal fecalomas represent an exceptionally rare etiology, with few cases reported in literature. This case study and literature review aim to highlight an unusual cause of small bowel obstruction, emphasizing the diagnostic challenges and management strategies.

Case presentation

A 60-year-old Middle Eastern female patient from Syria with a 1-year history of chronic constipation presented with abdominal pain, vomiting, and an inability to pass feces. Diagnostic imaging confirmed small bowel obstruction, which was caused by a fecal mass proximal to the ileocecal junction. Surgical extraction successfully resolved the obstruction.

Conclusion

This case underscores the importance of considering fecal impaction as a differential diagnosis in patients with chronic constipation and highlights the effectiveness of surgical intervention in resolving such obstructions. A comprehensive review of literature on unusual causes of small bowel obstruction, including imaging characteristics and management approaches, is also provided to enhance clinical awareness and improve patient outcomes.

Introduction

Fecaloma is a rare medical condition in which hardened feces form a distinct mass, primarily impacting the rectum and sigmoid colon. However, its occurrence in the small intestines, such as at the ileocecal junction, is exceedingly rare [1]. It can present in multiple ways: as an abdominal mass, stercoral colitis, urinary retention, and intestinal obstruction, mostly causing symptoms of fever, abdominal pain, vomiting, and diarrhea, commonly associated with chronic constipation [2]. This differs from typical fecal impaction, as the fecal material aggregates into a separate, solid mass. Several causes of fecaloma are described in literature, including Hirschsprung’s disease, mental health conditions, Chagas disease, inflammatory and neoplastic diseases, and chronic constipation [3]. Diagnostic methods are usually radiological, noting a characteristic intraluminal mass on plain X-rays, barium enema, or abdominal computed tomography (CT) [1]. Most patients with fecaloma can be managed within the primary care network with initial resuscitation, radiological confirmation of diagnosis, conservative management with nasogastric drainage, intravenous fluids, and output monitoring to guide fluid optimization. However, severe cases may require acute surgical intervention [1, 3, 4]. In this paper, we report a very rare case of a 60-year-old female patient with a year-long history of progressive constipation, who was diagnosed with small bowel obstruction (SBO) owing to fecaloma after further investigation.

Case presentation

A 60-year-old Middle Eastern female patient from Syria presented with symptoms of abdominal pain, vomiting, and inability to pass feces. Her medical history was notable for chronic constipation over the previous year and a hysterectomy performed 8 years prior. No significant psychiatric or other medical history was noted.

A thorough examination was conducted, and an abdominal X-ray revealed signs of small bowel obstruction. CT imaging revealed a narrowing transitional zone of the jejunal loops above the left iliac fossa. Semifecal content was observed above this area, suggesting a possible mechanical obstruction (Fig. 1a, b). Additionally, there was a 6 cm gastroesophageal herniation through the diaphragm. No obvious mass- or nonmass-related cause for the obstruction was identified, which suggested the possibility of adhesions. The uterus was surgically absent due to the previous hysterectomy. A small amount of free fluid was present in the pelvis, and bilateral parapelvic cysts were detected, but no other overt pathological changes were observed. However, a gastric endoscopy did not yield any significant findings.

Fig. 1

a Narrowing transitional zone of the jejunal loops above the left iliac fossa, b severe luminal narrowing of the intestinal loop with localized posterior wall thickening and proximal intestinal dilation

The initial diagnosis suggested that the obstruction was due to adhesions, especially considering the patient’s previous surgical history. The patient underwent laparoscopic surgery to address possible adhesions causing the obstruction. Intraoperative findings revealed a mass 70 cm proximal to the ileocecal junction, identified as the cause of the obstruction. Upon opening the abdomen, it was discovered that the mass was actually a fecal mass, which was then removed surgically (Fig. 2a, b). This diagnosis was consistent with her history of chronic constipation. The patient was successfully managed postoperatively and discharged the following day. Follow-up results showed complete resolution of the obstruction with no further complications, demonstrating the effectiveness of surgical intervention in such cases.

Fig. 2

a Fecal mass causing obstruction proximal to the ileocecal junction, b the fecal mass after surgical extraction

Discussion and conclusion

Fecaloma, a rare medical condition, was first described by Abella et al. in 1967 as a hardened mass of feces primarily affecting the sigmoid colon and rectum. Although usually found in the colon, fecalomas can rarely occur in the small intestine [3]. The prevalence of ileal fecaloma is relatively low and not commonly encountered in clinical practice [5]. The exact prevalence is not well documented owing to its rarity, and most cases reported in medical literature are isolated incidents or small case series [1, 2]. Fecalomas are solid masses of hardened stool observed in patients with various underlying conditions, such as chronic constipation, Hirschsprung’s disease, Chagas’ disease, inflammatory diseases, neoplastic diseases, and psychiatric disorders [1].

There are multiple causes of fecaloma formation, but in our case, the cause was not evident, although there was a history of altered bowel habits. Our patient presented with chronic constipation that had persisted for 1 year, though the specific cause remained undetermined. Moreover, our case presents a rare occurrence of fecaloma in the distal small intestine that led to progressing mechanical obstruction, resulting in symptoms, such as abdominal pain, vomiting, and dyschezia.

Elderly patients, particularly those hospitalized for extended periods, have a notable susceptibility, with slightly over a third experiencing fecal impaction during their hospital stay [3]. Our patient, aged 60 years, fell into this demographic category; however, she did not have any history of hospital stays. This case underscores the importance of considering fecaloma in the differential diagnosis of small bowel obstruction. Fecalomas in the small intestine can cause rapid mechanical obstruction, with symptoms, such as abdominal pain, distension, vomiting, and constipation [2]. Severe complications can arise, such as toxic megacolon and bowel obstruction [3]. These symptoms are often nonspecific, encompassing features, such as overflow-type diarrhea, unintended weight loss, detection of an abdominal mass, urinary retention, and vague abdominal discomfort following meals [2]. The patient in this study presented with complaints of abdominal pain, vomiting, and difficulty passing stool.

Differential diagnoses for fecalomas include other causes of bowel obstruction, such as enteroliths, fecaliths, adhesions, and neoplasms, which differ in their clinical presentation and diagnostic approaches.

Adhesions account for approximately two-thirds of SBO cases, with their incidence increasing owing to more laparotomies. Although adhesions develop in over 90% of laparotomy patients, only around 5% of abdominopelvic surgeries result in SBO. Radiographic findings show an abrupt transition from dilated to collapsed small intestine, with the small bowel feces sign often seen proximal to the obstruction. Neoplasms, particularly intrinsic colon carcinoma, cause about 55% of large bowel obstruction cases, manifesting as large soft tissue masses and complicating up to 20% of colon cancers. While adhesions are rarely visible on CT scans and diagnosed by exclusion, neoplasms are identifiable on CT or magnetic resonance imaging (MRI) [6].

Fecaliths, smaller hardened fecal concretions, can also cause acute bowel obstruction and are usually diagnosed using imaging modalities, such as an abdominal CT scan, owing to their smaller size and potential for causing acute symptoms. Fecaliths have been shown to be linked to different medical statues, such as individuals who have undergone gastric surgery (5–12%), particularly those with major distal gastrectomy, poor function of the remnant gastric, and absence of the pylorus, causing undigested food to enter the small intestine. Additionally, the incidence of fecalith formation is also linked to Meckel’s diverticulum and diabetes mellitus [7]. Enteroliths, on the other hand, are abnormal concretions that form within the intestines and are usually composed of mineral salts. They can cause fluctuating subacute intestinal obstruction or present as surgical emergencies, such as acute intestinal obstruction, hemorrhage, and bowel perforations [8].

Differentiating previous possible diagnoses from ileal fecaloma often requires a combination of patient history, physical examination, and imaging techniques, such as abdominal X-rays and CT scans, which reveal dilated intestinal loops and the presence of a radiopaque mass. Furthermore, abdominal ultrasound can reveal an echogenic mass with posterior acoustic shadowing, while barium enema or small bowel series may reveal a filling defect. Endoscopy can be used to provide direct visualization and confirm the exact location of the obstruction [6,7,8,9].

There is no formal protocol, but fecalomas can typically be managed with conservative treatments, such as laxatives, enemas, and manual evacuation. In cases where these methods fail, surgical intervention may become necessary. This is especially true when fecalomas cause small bowel obstruction, as highlighted by case studies where conservative management was insufficient and surgical intervention was required [1, 2]. All published cases of small bowel obstruction due to fecalomas required surgical intervention [2]. In this study’s case, the patient underwent laparoscopic surgery first, followed by open surgery, to remove the hardened fecal mass and relieve the obstruction and symptoms.

While our patient experienced an uneventful recovery, a systematic review of complications of fecal impaction showed that intestinal obstruction accounts for 13%, while 67% were complications on the intestinal wall, such as perforation, stercoral ulcer, strangulation, prolonged enteral starvation, and single or multiorgan failure [2, 10].