A 73-Year-Old Man with Long-Term Immobility Presenting with Abdominal Pain

Salomone Di Saverio and colleagues discuss the diagnosis and management of a man presenting with symptoms of partial intestinal obstruction.

In summer 2008, a 73-year-old man arrived in the emergency room with vague abdominal pain. On examination, his abdomen was distended and tympanic, but soft and non-tender on palpation. The patient had been immobile and bedridden since 1995, when he had neurosurgical resection of a medullary ependymoma of the spine, with residual paraplegia, peripheral neuropathy, and a neuropathic bladder with secondary chronic renal failure. The patient had a medical history of hypertension and type II diabetes mellitus and suffered from chronic constipation with recurrent episodes of partial bowel obstruction.
Given his past history, the current presentation was in keeping with a further episode of bowel obstruction. At this stage, we needed to assess the degree of obstruction (complete or partial) and its possible causes.

What Investigations Are Required in Assessing Bowel Obstruction?
The full diagnostic workup is shown in Box 1, and Figure 1 shows a flow diagram for diagnostic assessment of bowel obstruction. The usual sequence of investigations starts with plain abdominal X-ray (see Figure 1). In the absence of grossly distended bowel loops on X-ray, and if the patient's condition is stable, ultrasound can be useful to rule out (1) other conditions or diseases causing paralytic ileus or (2) the presence of intraperitoneal free fluid. If the plain abdominal X-ray shows air fluid levels and grossly distended bowel loops, the level and possible site of obstruction must be assessed (i.e., small bowel or large bowel), and the further diagnostic workup proceeds accordingly. When in doubt, or when the clinical and radiological findings are not clear enough to suggest the best further diagnostic steps, abdominal computed tomography (CT) scan may be helpful, with the eventual adjunct of triple contrast (intravenous, oral, and/or rectal). The last diagnostic options are diagnostic laparoscopy or exploratory laparotomy.
Plain abdominal X-ray was ordered. This showed a huge faecal impaction extending from the pelvis upwards to the left subphrenic space and from the left towards the right flank, measuring over 40 cm in length and 33 cm in width ( Figure 2). There was also massive dilatation of the descending and sigmoid colon.

At This Stage, What Was Our Differential Diagnosis?
This patient has partial large bowel obstruction. The differential diagnosis is between malignant obstructing diseases, such as colon cancer, or benign conditions, such as sigmoid volvulus or diverticulitis.
The Learning Forum discusses an important clinical problem of relevance to a general medical audience. N CT scan N Conventional barium follow-through examination, upper gastrointestinal and small bowel series, enteroclysis (fluoroscopic X-ray of the small intestine) [18] N Water-soluble contrast follow-through (this investigation is safer than barium in cases of perforation and peritoneal spread and has possible therapeutic value in the case of adhesive small intestine obstruction [19]) N Contrast (barium or water-soluble) enema N CT scan with double contrast (intravenous and oral or rectal) N Magnetic resonance imaging N Endoscopy (colonoscopy, esophagogastroduodenoscopy, ileoscopy) N Laparoscopy These benign conditions can be lifethreatening because of the risk of colonic ischaemia and/or perforation.
Given the history of recurrent chronic constipation, in a chronically bed-ridden patient with previous spinal surgery and residual paraplegia, we thought it was likely that this patient had faecal impaction without an anatomical lesion causing the impaction. Pinpointing the exact cause of the constipation in this patient was difficult, as he had a complex medical history and presentation-renal failure, dehydration, electrolyte imbalance, diabetes mellitus, and peripheral neuropathy and paraplegia secondary to spinal cord tumour, in an immobile bed-ridden patient with mild depression. In patients receiving palliative care, the underlying causal factors for constipation are likely to be long-standing. The patient's bowel pattern needs to be carefully assessed, with a focus on looking for modifiable factors. For example, if a particular pharmacological agent is identified as a possible causative factor, it may be helpful to change the agent or the route of its administration. It is also helpful to anticipate the constipating effects of medications, such as opioids, and to provide laxatives prophylactically. Other concomitant or contributing factors such as electrolyte imbalances or metabol-
In this patient, a long colonic-rectal tube was inserted with partial relief of the abdominal distension after expulsion of 8,000 ml of gas. The patient was admitted to the medical ward for rehydration, correction of electrolyte imbalance, and multiple enemas. Two days later the faecal impaction, although slightly reduced, still measured 32 cm in length and 24 cm in width ( Figure 3). After ten days of conservative treatment, the abdomen remained visibly distended ( Figure 4).

Which Diagnostic Exam Would Now Be Helpful?
Serial plain abdominal X-rays had already been performed. Colonoscopy was not feasible, because the severe faecal impaction may have hindered the progression of the endoscope and affected the sensitivity of the exam by covering and camouflaging possible mucosal lesions of the colonic wall. Contrast enema would probably not have been effective or diagnostic. Therefore abdominal CT scan with multiplanar reconstruction and threedimensional (3-D) reconstruction appeared to be the best option as a further diagnostic step, in order to assess the presence of an anatomic cause for the patient's bowel obstruction.
Abdominal CT scan was ordered. The multiplanar and 3-D reconstruction showed the persistence of a large faecal impaction, over 18 cm in extent ( Figure 5), in the sigmoid colon. There was massive N Painful anorectal conditions (haemorrhoids, anal fissure, perianal abscess)

Functional Factors
N Diet: Poor appetite and low amounts of food intake, low-fibre diet, poor fluid intake N Environmental: Lack of privacy, comfort, or assistance with toileting N Other factors: Advanced age, inactivity, decreased mobility, bed-ridden patients, depression, sedation It is likely that the abnormally dilated descending colon was exacerbating the neurogenic chronic faecal stagnation ( Figure 6).

What Was the Next Step in Managing This Condition?
Rehydration, multiple enemas, the prokinetic agent neostigmine (see Box 4), and laxatives were continued with gradual relief of the bowel obstruction and resolution of the faecal impaction.
We believed that neostigmine, which has a focused effect in stimulating large bowel motility, was the most appropriate and beneficial prokinetic agent in this setting (it is also appropriate in patients with colonic pseudo-obstruction).
The patient was scheduled for elective surgical resection of the redundant megacolon. He was discharged 25 days after admission, after rehydration, multiple enemas, prokinetic agents, and laxatives. On discharge, the abdomen remained slightly distended but was soft and nontender. The patient was passing stools and not vomiting. We suggested home nursing to the patient and his family.
After discharge, he underwent elective surgical resection of the redundant megaco-  lon with planned primary anastomosis, and he had an uneventful postoperative course.
The patient gave written consent for these case details to be published.

Discussion
If people in Western societies continue to live longer, we are likely to see an increase in the number of institutionalised elderly people with impaired mobility. Both ageing and immobility are risk factors for constipation. The estimated prevalence of constipation is between 2%-28%, and the number of people reporting constipation increases with age [2][3][4]. Constipation is more severe in those with pre-existing neurological illness and injury [5,6]. A US study found that constipation was more common in women, African Americans, people from lower socioeconomic levels, and those living in rural areas and northern states [7]. Faecal impaction is common in frail ill elderly people or in people of any age if they have a neurologic impairment (e.g., spinal cord injury, stroke, multiple sclerosis, spina bifida).
The prevalence of constipation among patients in palliative care ranges from 32% to 87%, and it is particularly common in patients with end-stage cancer [8][9][10]. The combination of physical illness and hospitalisation may cause and/or worsen constipation. About 50% of patients admitted to hospices cite constipation as a main concern [11], and this is the third most common symptom after pain and anorexia in patients in hospices.

Complications of Constipation
In severe constipation, patients are usually unable to pass much stool and may pass only small amounts of watery stool. They typically experience abdominal pain, discomfort and bloating, and may also lose their appetite. Some very ill older patients may have a change in behaviour and may develop fever.
In patients with constipation associated with a sigmoid redundant megacolon, colonic volvulus can develop, with possible progression to bowel wall ischaemia and perforation. Early surgical consultation and laparotomy are mandatory in such cases.

Treatment of Constipation
Treatment of constipation, and of the most severe forms of faecal impaction, is multimodal [12]. If a large impaction is present, it may need to be broken up manually, using lubricated gloved fingers with patients lying on their left side [13].  Multiple enemas with sodium phosphate and soapsuds [14], or even with natural mixtures such as milk and molasses, can contribute to removing any leftover stool (a clinical trial of a milk and molasses enema for childhood constipation is underway in the US; see http://clinicaltrials. gov/ct2/show/NCT00467350).
Fibres and laxatives can increase stool frequency and improve symptoms of constipation [15]. Pulsed irrigation of faecal impaction is also used for bowel management in patients with chronic constipation. It has been used primarily in patients with neuropathic bowel who have failed conservative therapy. Hospitalisation for rehydration and electrolyte imbalance correction is required for some patients, and in the most severe cases manual disimpaction under general anaesthesia is required [16].
Diagnostic assessment for colonic diseases is not routinely required. Such assessment is usually reserved for patients whose constipation is refractory to conservative treatment, or who have persistent severe faecal impaction, and/or who are found to have concomitant colonic obstructive disease.
Management of chronic constipation is shown in Box 5. The different levels and steps in managing chronic constipation should be focused on the different underlying conditions and needs of patients. Management is primarily conservative for patients with mild long-term constipation, in younger patients, and in those who are otherwise healthy and will adhere to a conservative regime. Medical treatment should be initiated for moderate-to-severe constipation, in the elderly, institutionalised, critically ill, or neurologically impaired, and in patients in palliative care and who are at the end of their lives. Surgical treatment should be reserved for selected patients (see Box 5) and/or constipation that is persistent and unresponsive to the other treatments.

Managing Constipation in Palliative Care
In palliative care, nursing staff play a crucial role in the assessment, prophylaxis, and management of constipation, since they are in daily contact with patients. Such assessments should focus not only on the frequency of bowel movements, but also on the quality of stools; length of time to defecation; diarrhoea and overflow diarrhoea; continence and incontinence; effectiveness of laxatives; addition of complementary therapies worsening constipation; diet and fluid intake; environmental factors that could be influencing N Repair of non-emptying rectoceles for patients with obstructed defecation N Subtotal colectomy with ileorectal anastomosis for patients with persistent and intractable slow transit constipation N Patients with combined slow transit constipation and pelvic outlet obstruction, as well as symptomatic refractory retaining rectoceles and rectal intussusception, benefit from subtotal colectomy with ileorectal anastomosis and repair or treatment of the outlet obstruction causing pathology bowel movements (i.e., comfort and privacy); and the need for abdominal massage. Abdominal massage, performed by a massage therapist, may be used in patients with chronic constipation and altered motility as an adjunctive measure; it may help to stimulate the periphery of the small and large intestines and relieve bowel atony. A recent randomised controlled trial of abdominal massage plus laxatives versus laxatives alone for constipation found that the addition of massage was associated with decreased constipation and abdominal pain and increased bowel frequency [17]. Larkin and colleagues recently published an algorithm on prophylaxis, ongoing assessment, and treatment of constipation in palliative care settings [1]. Ongoing monitoring for early symptoms of constipation and patient education are the cornerstones of prophylaxis. The first step in treatment should be a careful assessment to confirm constipation and exclude malignant causes of intestinal obstruction. The next step is the identification and treatment of correctable causes. If the cause is not correctable, first-line treatment should be with oral laxatives (a combination of softener and stimulants according to patient needs [1]). If this treatment improves symptoms, it should be continued; otherwise a second-line treatment should be adopted. Standard second-line treatment is a rectal suppository and enema. If first-line and secondline treatments fail, the third-line treatment is manual evacuation. During second-line and third-line treatment, adding a peripheral opioid antagonist may be helpful if the patient is taking opioids.