Saint Michael's Medical Center Harrison, NJ, United States
Muhammad Hussain, MD1, FNU Marium, MD2, Saraswathi Lakkasani, MD3, Theodore Dacosta Jr., MD3, Yatinder Bains, MD3 1Saint Michael's Medical Center, Harrison, NJ; 2Saint Michaels Medical Center, Harrison, NJ; 3Saint Michael's Medical Center, Newark, NJ
Introduction: Constipation is a common challenge in clinical practice. Common complications of fecalomas include intestinal obstruction, colonic ulceration, and stercoral perforation, rarely it involves the urinary system due to mass effect. We present an interesting case of bilateral hydroureteronephrosis and urinary bladder outlet obstruction secondary to fecaloma.
Case Description/Methods: 87 YO male with PMH HTN, DLD, diabetes, CKD, BPH, CAD, hx of ischemic colitis, CVA w/o any residual effects presented with nausea, NBNB vomiting, low urine output, generalized abdominal pain for 1 week. Patient was a former smoker with 30 pack-year history. Vitals were unremarkable. Exam showed abdominal distention w/o any rebound tenderness. Rectal exam was refused by the pt. Workup showed WBC 12.1, Hb 11.1, platelets 292, BUN > 150, Cr 5.1, HCO3of 17. ABG showed metabolic acidosis with PH of 7.28 and PCO2 31. UA was significant for UTI and proteinuria. Non-contrast CT abdomen showed a massive amount of stool in the rectosigmoid with marked distention of the rectosigmoid to 13 cm which displaces urinary bladder anteriorly causing urinary bladder outlet obstruction and bilateral hydroureteronephrosis. Foleys inserted by the urology drained 1800 cc. As per general surgery recommendation, the patient was kept NPO, NG tube was placed, and started with IV zosyn and enemas. Patient refused manual disimpaction and enemas so lactulose was started. Patient was also started on a bicarbonate drip. patient creatinine trended down to his baseline. Subsequently, patient had a large bowel movement, and repeat X-ray abdomen showed distention of large and small bowel but much less stool in the rectosigmoid colon as compared to the CT scan. However, patient passed away in the next couple of days due to worsening of his condition due to multiple comorbidities.
Discussion: Fecaloma causing bilateral hydroureteronephrosis is an uncommon entity in routine practice. Sigmoid colon and rectum are the two regions where fecaloma is frequently seen. Due to the local pressurizing effect of fecaloma (pelvic mass effect), severe morbidity such as urinary system obstruction and rupture of colon or bladder may occur, and sometimes they can be mortal.