fecaloma

Fecaloma in a Young Boy

Nisha Polavarapu, MD, and Noah Kondamudi, MD, MBA

A 4-year-old boy with chronic constipation presented to the pediatric emergency department with abdominal pain and no bowel movement for 4 days. The patient has been given polyethylene glycol intermittently to aid in bowel movements. The parents of the patient reported that the child was otherwise healthy, and they denied that he had any nausea, vomiting, or fever.

On physical examination, the patient’s lower abdomen appeared distended with some tenderness localized to the lower abdomen. A firm mass was palpable over the right lower and hypogastric quadrants with well-defined margins and hyperactive bowel sounds. There was no rebound tenderness, guarding, or rigidity. Obturator and psoas signs were negative and there was no hepatosplenomegaly. The remainder of the physical examination results were unremarkable. 

Plain abdominal radiography (Figure) revealed an intraluminal mass with soap bubble appearance compatible with fecaloma that resolved after multiple enemas.

Discussion

The differential diagnosis among children presenting with an abdominal mass is wide.1 Neoplasms such as neuroblastoma, Wilms tumor, lymphoma, hepatoblastoma, embryonal sarcoma, teratomas, and rhabdoid tumors are of particular concern. Ovarian cysts, gastrointestinal duplication, Meckel diverticulum, Hirschprung disease, hydronephrosis, renal vein thrombosis, Chagas disease, and psychiatric diseases should also be included in the differential diagnosis.2-4 

Fecaloma results from the accumulation of fecal material and can include intestinal debris and deposits of calcium soaps.5 Fecal matter accumulates in the intestine, then stagnates and increases in volume until the intestine becomes deformed and acquires characteristics similar to those of a tumor.6 Complications include colonic obstruction, perforation, sciatica, ureter obstruction, secondary hydronephrosis, and deep vein thrombosis.7

Patients with fecalomas can be managed conservatively with laxatives, enemas, and digital evacuation. When these measures fail, surgical intervention is often required.7,8 However, Lee and Kim9 reported a case of a fecaloma that was successfully removed by endoscopic fragmentation with Coca-Cola injection instead of surgery.n

Nisha Polavarapu, MD, and Noah Kondamudi, MD, MBA, are from the department of pediatrics and emergency medicine at Rutgers New Jersey Medical School in Newark.

References 

1. Savage RR, Brinn MC. Abdominal mass. In: Perkin RM, Swift JD, Newton DA, Anas NG, eds. Pediatric Hospital Medicine. Textbook of In-Patient Management. 2nd ed. Lippincott Williams & Wilkins. Philadelphia, PA: 2008;75-76.

2. Kim KH, Kim YS, Seo GS, Choi CS, Choi SC. Case reports: a case of fecaloma resulting in the rectosigmoid megacolon. Korean J Neurogastroenterol Motil. 2007;13(1):81-85.

3. Campbell JB, Robinson AE. Hirschsprung’s disease presenting as calcified fecaloma. Pediatr Radiol. 1973;1(3):161-163. 

4. Araki T, Miki C, Yoshiyama S, Toiyama Y, Sakamoto N, Kusunoki M. Total proctocolectomy and ileal J-pouch anal anastomosis for chagasic megacolon with fecaloma: report of a case. Surg Today. 2006;36(3):277-279.

5. Kantarci M, Fil F. Gastrointestinal: fecaloma in a dilated sigmoid colon.
J Gastroenterol Hepatol. 2007;22(6):955. 

6. Garisto JD, Campillo L, Edwards E, Harbour M, Ermocilla R. Giant fecaloma in a 12-year-old boy: a case report. Cases J. 2009;2(1):127. 

7. Yoo HY, Park HW, Chang SH, Bae SH. Ileal fecaloma presenting with small bowel obstruction. Pediatr Gastroenterol Hepatol Nutr. 2015;18(3):193-196.

8. Rajagopal A, Martin J. Giant fecaloma with idiopathic sigmoid megacolon: report of a case and review of the literature. Dis Colon Rectum. 2002;45(6):833-835.

9. Lee JJ, Kim JW. Successful removal of hard sigmoid fecaloma using endoscopic cola injection. Korean J Gastroenterol. 2015;66(1):46-49.