A new approach in the treatment of faecaloma of the colon
Authors: Khera G , Shea AJ , Lambrianides AL 
Published: May 2014

A 43-year-old woman presented with a 12-hour history of colicky abdominal pain increasing in severity and frequency. There was nausea but no vomiting. She last opened her bowels and passed flatus 48 hours before and otherwise had no history of constipation. There was no recent change in bowel habit and no blood or mucus per rectum. There had been no systemic disturbance and there was no family history of malignancy of the large intestine. The only surgical history was an appendicectomy performed at the age of 39 years. There was no relevant medical history.

On clinical examination, the patient was apyrexial, normotensive, tachycardic and distressed. The abdomen was distended and tympanic but with no signs of peritonism. There was a palpable non-tender mass in the left lower abdominal quadrant. Her basic haematology and biochemistry were unremarkable; plain radiography of the chest showed a right basal pleural effusion with some patchy collapse at the right lung base. Erect and supine abdominal radiographs showed severe distension of the colon with only slight dilatation of the small intestine and multiple fluid levels. A computed tomograph examination of the abdomen and pelvis (Figure 1) showed free fluid in the pelvis and a small amount of inflammatory change in the fat of the abdominal cavity. There was extensive dilatation of the large intestine, with only slight dilatation of the small intestine. The appearances were consistant with a distal large bowel obstruction with an essentially competent ileocaecal valve. A large faecal sphere was shown in the sigmoid colon, which appeared rather thick-walled. There was no evidence of free peritoneal gas. A gastrografin enema showed a rounded filling defect in the upper sigmoid colon.

Following a period of resuscitation, the patient was taken to theatre for colonoscopy to exclude a malignant or benign stricture and to attempt to disrupt the faecaloma to relieve the large bowel obstruction and avoid proximal and/or local perforation. The procedure was performed under general anaesthetic with the patient in the lithotomy position and with an arrangement to proceed to laparotomy should the colonoscopy procedure fail. Colonoscopy showed a faecal mass 55 cm from the anal verge, which proved resistant to all attempts at dislodging and disruption. A size 18F nasogastric tube (NGT) was inserted under direct vision through the anus and past the faecal obstruction (Figure 2). The proximal large intestine was successfully decompressed with the NGT. Liquid paraffin 200 ml was injected proximal to the faecaloma. In the post-procedure period, care was taken to keep the lumen of the NGT clear by an occasional injection of normal saline (30 ml hourly) to ensure free drainage. The catheter was left in situ. The patient was returned to theatre the next morning for a repeat colonoscopy. On this occasion the faecal mass was noted to be slowly showing signs of fragmentation and softening (Figure 3). Vigorous saline irrigation completely disrupted the mass with relief of the obstruction. There was an area of superficial ulceration at the site of the impaction but no evidence of a benign or neoplastic stricture.

Subsequent colonoscopy 3 weeks later showed no abnormalities, with the superficial ulceration completely healed and benign biopsies.

The patient remains well 6 months after the episode and has increased her fibre intake and now exercises regularly.