A young man had lost 50 lb in two months and was having bowel movements almost hourly
A 19-year-old Caucasian man was referred to the gastroenterology department for a two-week history of severe diarrhea and six weeks of appetite loss and weight decrease. He reported between 20-25 diarrheal bowel movements daily, with symptoms occurring during the day as well as at night. He also complained of abdominal cramping and heartburn. He reported no fever, chills, night sweats, nausea, vomiting, melena, hematochezia, or hematemesis. He did report a significant weight loss of 50 lb over the past two months but later admitted he was using crack cocaine and a number of other narcotic agents on a daily basis at the time of his weight loss. Since discontinuing recreational drugs, his weight had stabilized.
His past medical history included gastroesophogeal reflux disease (which was generally well controlled with ranitidine [Zantac] 150 mg b.i.d.), drug abuse and, interestingly, constipation. He reported no allergies. Besides the ranitidine, he was taking loperamide (Imodium), which a primary-care provider prescribed for the current diarrhea. The patient had never undergone any surgical operations. He smoked one pack of cigarettes a day and had done so for the past five years. On weekends, he consumed a couple of alcoholic beverages. He was single, had no children, and was unemployed. His father had hepatitis C and anal fissures, his mother and a brother had depression, and another brother had CAD.
On physical examination, the patient’s BP was 130/80 mm Hg, pulse 60 beats per minute, and weight 151 lb. The man was alert, oriented, in mild distress, and complaining of abdominal discomfort. His lungs were clear; his heart had a regular rate and rhythm. His skin was warm, dry, and acyanotic with good turgor and without clubbing, edema, or jaundice.
The man’s abdomen was firm, slightly distended with generalized tenderness, and dull to percussion, with a palpable mass to the left of the umbilicus. There was no rebound or guarding. Rectal exam was attempted but not completed due to extreme discomfort. External anal exam revealed old hemorrhoidal tags.
A complete blood count, erythrocyte sedimentation rate, comprehensive metabolic profile, amylase, and lipase levels were all within normal limits. Supine and erect films of the abdomen (Figure 1) revealed severe fecal impaction and dramatic rectal distension. The films also noted the presence of barium, particularly in the rectum. When initially interviewed, the patient denied undergoing any diagnostic tests prior to his current evaluation. However, since he obviously had a colon full of barium, he was questioned again and remembered undergoing an upper GI x-ray three weeks before as part of the workup for his weight loss.
Although the presenting symptom was diarrhea, the diagnosis was clearly constipation with overflow diarrhea. The severe pain elicited on rectal exam was later found to be the result of anal fissures, likely caused by chronic constipation. Had the rectal exam been successful, a rock-hard mass would likely have been felt, due to the presence of a mixture of firm stool and dried-out barium.
Overflow diarrhea results from fecal impaction, with frequent passage of liquid stool around the impacted mass of hard stool.1 While a commonly recognized consequence of neurologic damage, fecal impaction can result from narcotic use.2 This patient’s drug use likely worsened his underlying constipation. The fact that he ingested barium three weeks prior to the most recent x-ray and continued to show large amounts of dye speaks volumes for his baseline state of constipation.
This case illustrates the importance of a thorough health history and a rectal exam in a patient with new-onset severe diarrhea. This man’s long-standing history of constipation abruptly shifted toward severe diarrhea. Certainly, any change in bowel habits should be thoroughly evaluated, particularly if alarm symptoms, such as the weight loss reported in this case and the mass palpated on exam, are present. On initial evaluation, this case would send shivers down the spine of any clinician. Fortunately, the patient’s potentially life-altering problem turned out to be benign. The palpable mass disappeared as his constipation was corrected.
Because of the severe pain secondary to anal fissures, the patient was sedated and manually disimpacted. Full colonoscopic evaluation identified no additional pathology. This man would benefit from a high-fiber/high-fluid diet, regular exercise, and a daily laxative regimen. Ideally, he should undergo a Sitz marker x-ray in which a number of small “rings” are swallowed and sequential plain films obtained over a number of days to determine if the entire colon is lax (colonic inertia) or a particular part of the colon is not working. The latter is often seen with neurologic damage, as caused by Hirschsprung’s disease or cauda equine syndrome. In addition, anorectal manometry is frequently helpful to evaluate rectal sensation and function. Unfortunately, the patient never returned to the clinic and was lost to follow-up.
Mr. Askey is a certified registered nurse practitioner in the Department of Hepatology/ Gastroenterology at the Guthrie Clinic in Sayre, Pa., and a contributing editor to The Clinical Advisor.
1. Scarlett Y. Medical management of fecal incontinence. Gastroenterology. 2004;126(1 Suppl 1):S55-S63.
2. Rao SS. Pathophysiology of adult fecal incontinence. Gastroenterology. 2004; 126(1 Suppl 1):S14-S22.