Dr Rithwik Sunil, Dr C Jayakumar , Dr Praveena N B
Sixteen year old male child, a case of Lennox Gastaut Syndrome, GDD, Failure to thrive, symptomatic epilepsy on multiple AEDs,presented with foul smelling loose not blood stained ,5-6 episodes per day . He had history of low grade intermittent fever of 1 day duration, not associated with chills and rigor. He also had history of lethargy and fatigue. He has a history of constipation from 5 years of age. Child was then referred to AIMS for further evaluation and management.
Development history: Gross motor – Standing with support attained at 8 years of age Language – Cooing attained at 2 years of age
Social skill – Social smile attained at 2 months of age Immunization history:
Only birth dose vaccines taken
CLINICAL EXAMINATION :
At admission:Child was tired looking and lethargicVitals:Vitals,PICCLE normal
Auxology:Weight: 40kg (b/w 3rd and 10th centile)
Length 128cm (below 3rd centile)BMI: 24.4 kg/m2 (b/w 85th and 97th centile)Head Circumference: 53cmHead to foot examination: Sunken eyes, dry lips, limb contractures +
Systemic ExaminationGIT : Hard mass palpable in Left iliac fossa
RS: AEBE, NVBS, No additional soundsCVS: S1 S2 +,No murmurs
CNS: cranial nerves normal
Motor System:Bulk: Generalized wasting +, Tone: Spasticity +, Power: 2/5 in Right UL, 3/5 in Left UL; 2/5
in bilateral LL, reflexes couldn’t be assessedSensory system: normal, No cerebellar signs, no signs of meningeal irritation.
Examination revealed large hard mass present in the left iliac fossa. Child was passing foul smelling stool everyday.
Xray Abdomen was then taken revealed a large circular mass in the bowel suspected to be a large faecaloma
Faecaloma present in the bowel
Saline enema administered followed passage of fecal mass. Pediatric gastroenterology consult sought i/v/o h/o chronic constipation and started Enflush enema. Repeat X ray Abdomen done showed reduction in fecolith size and peglecwas started. Subsequently, he was passing stools normally every day.
Resolution of faecaloma
Faecaloma
Chronic constipation is common in pediatrics, representing 3–5% of general outpatient visits and up to 25% of gastroenterology consultations. Treatments include dietary, pharmacological approaches (laxatives, prokinetics), behavioraltherapy, and, in extreme cases, surgery. Fecalimpaction is defined as accumulation of hard stool in the anorectum. Disimpaction, to remove the hard fecal mass, is required before commencing maintenance therapy for constipation. PEG is the gold‐standard laxative treatment for constipation as it is well investigated, safe and effective, and suitable for chronic use.
Take Home message
Fecaloma should be considered in the differential diagnosis of any patient with history of chronic constipation and abdominal mass. Often the diagnosis can be made from the clinical and radiologic features. In the beginning, therapy should be conservative. Rarely laparotomy is required to remove the mass