Unusual radiographic appearance of Fecalith leading to acute abdomen in a patient consuming Iron: A Case Report

doi:10.21203/rs.3.rs-5211985/v1

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Case Report

Unusual radiographic appearance of Fecalith leading to acute abdomen in a patient consuming Iron: A Case Report

https://doi.org/10.21203/rs.3.rs-5211985/v1

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Background: Fecalith is common clinical condition, delay in diagnosis and management can lead to life threatening complications.

Case Presentation: We are reporting the case of an 18 years old lady which have unusual radiographic appearance of fecalith which was diagnosed in rural emergency setting and managed with simple conservative approach.

Conclusion: Fecalith can present with acute abdomen and confusing radiographic picture. It can lead to life-threatening bowel complications but can be managed conservatively with early diagnosis.

Acute Abdomen

Fecalith

Large

Radiography

Fecal impaction is a frequent cause of emergency department visits.(1) Although it is an easily manageable condition, it can lead to serious complications such as bowel perforation and may become life-threatening.(2) Here, we present a case of acute abdomen caused by a fecalith which was successfully managed.

We are reporting the case of an 18-year-old unmarried female who presented to our center with sudden onset of colicky abdominal pain. The patient described the pain similar to bearing down effort explaining like ‘something coming out of the vagina’ which progressively worsened over 24 hours and was associated with mild abdominal distension. She had not passed stool for the past 4 days and had not passed flatus for the last 24 hours. Prior to this, she gave a history of consumption of iron tablets prescribed with oral contraceptive pills. There is no history of similar episodes in the past, no history of any neurological disorder, chronic constipation, or any other medical condition.

On examination, the vital signs were stable but she reported pain score of 10/10 in visual analogue scale, and the abdomen was soft with mild hypogastric tenderness. Initially, bowel or ureteric colic was suspected and we started treatment with hyoscine and intravenous ketorolac. However, the pain persisted necessitating the addition of intravenous tramadol, which also failed to provide significant relief.

We ordered an abdominal radiograph which revealed a well-defined spherical radiopacity in front of the sacral bone and behind the pubic symphysis along with mild dilation of proximal bowel wall as shown in Figure 1 and 2. This was followed by an ultrasonography which showed that the uterus and urinary bladder were normal and there was a well-defined hyperechoic lesion behind the uterus with posterior acoustic shadowing Media 1. On per rectal examination, the perineum appeared normal with an intact anal opening, but a well-defined mass was felt, which stained the gloves with a substance resembling black mud. By making the working diagnosis of fecalith, we managed the case by digital fragmentation of the lesion followed by 200 ml of soap water enema after which she passed the stool and the pain subsided. Repeat abdominal X-Ray and ultrasonography produced normal findings Figure 3. Later the patient was discharged with oral medication and she was doing well with no any further complain even at 1 week follow up.

Fecal impaction is a common occurrence in an emergency department, typically in a patient with a history of chronic constipation. However, its presentation with severe abdominal pain along with bearing down sensation in a young female without a known co-morbidity is very unusual. (3) Previously it has been reported that high fiber diet like seeds is commonly associated with fecal impaction. Large radiopaque fecalith has been reported in some studies, the association with iron consumption, as observed in our case, is unique and warrants further investigation through well-designed study.(4) (5)

Our patient presented with severe abdominal pain with bearing down effort which was not controlled by first line analgesia, potentially leading us to an incorrect diagnosis. Abdominal radiography is one of the most commonly used diagnostic modality in children and adolescents and it helps in diagnosis of fecalith. We found one reported case of large fecalith which was associated with an anorectal anomaly but no any case of a large fecalith in absence of chronic anorectal condition.(6) Although radiography is helpful in diagnosis of fecaliths, the radiographic findings in our case were unusual causing uncertainty in confirming diagnosis. In settings where a CT scan is unavailable, a high clinical suspicion combined with radiographic and ultrasonic studies can aid in diagnosis. (7)

Digital fragmentation combined with soap water enema helps in successful management and prevention of fatal complications.(8) Fecal impaction is more common in children and can potentially lead to life threating complications.(9)

Acknowledgement:

The authors are grateful to the patient and her family members for accepting our proposal to report this case.

Consent for publication:

Informed written consent was taken from the patient before writing the manuscript.

Competing interests:

None.

Funding:

None.

Ethical Approval:

Not Applicable

Authors' contribution:

Dr. Padam Raj Joshi and Dr. Niharika Pathak have taken the history, performed physical examination and were involved in the management of the patient. Dr. Sushil Sah, Dr. Megha Thapa, and Dr. Prakash Pandey were involved in writing the manuscript. Dr. Padam Raj Joshi and Dr. Niharika Pathak edited and revised the manuscript. All authors read and approved the final version of the manuscript.

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Hussain ZH, Whitehead DA, Lacy BE. Fecal Impaction. Curr Gastroenterol Rep. 2014;16(9).
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Reuchlin-Vroklage LM, Bierma-Zeinstra S, Benninga MA, Berger MY. Diagnostic value of abdominal radiography in constipated children: a systematic review. Arch Pediatr Adolesc Med [Internet]. 2005 Jul [cited 2024 Sep 8];159(7):671–8. https://pubmed.ncbi.nlm.nih.gov/15997002/
Chakravartty S, Chang A, Nunoo-Mensah J. A systematic review of stercoral perforation. Colorectal Dis [Internet]. 2013 Aug [cited 2024 Sep 14];15(8):930–5. https://pubmed.ncbi.nlm.nih.gov/23331762/
Corban C, Sommers T, Sengupta N, Jones M, Cheng V, Friedlander E et al. Fecal Impaction in the Emergency Department: An Analysis of Frequency and Associated Charges in 2011. J Clin Gastroenterol [Internet]. 2016 Aug 1 [cited 2024 Sep 14];50(7):572–7. https://pubmed.ncbi.nlm.nih.gov/26669560/

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Unusual radiographic appearance of Fecalith leading to acute abdomen in a patient consuming Iron: A Case Report

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