Initially, patients with Chagas' disease attempt to achieve normal evacuation using laxatives and enemas. Ultimately, these patients cease to worry about infrequent evacuation. This lack of bowel activity occurs despite increased refractoriness of the colon to cathartic compounds. The result is an accumulation of feces in the intestine, mostly in the sigmoid colon and even more so in the rectum; with time, the accumulated feces progressively dehydrate, becoming a hard fecal stone, the so-called fecaloma (Fig. 25.8). The authors have observed patients who have retained such fecalomas for up to 3 months.
The diagnosis is made by physical examination; a mass may be palpable either in the abdomen or in the rectum. A plain abdominal radiograph may reveal the fecaloma with its characteristic "breadcrumb" or "ground-glass" appearance. The treatment of the fecaloma depends on its location and duration.
Fecalomas that are not too hard can sometimes be resolved with intestinal lavage with saline irrigation. This procedure should only be performed in a hospital setting due to the risk of perforation. Scybalous stools require manual evacuation, preferably spinal anesthesia as a dis-impaction method. The feces need to be broken up and removed step by step initially with a finger, until the first and most hardened portions that acted as the plug have been removed. Following this procedure, intestinal lavage is undertaken with judicious use of lukewarm water, until the terminal portion of the intestine has been fully cleansed.
In rare cases the fecaloma may be located in the upper rectum or sigmoid colon. In such cases the above maneuver will be unsuccessful and laparotomy is indicated. The preferred operation is a Hartmann's procedure, with resection of the segment, which includes the fecaloma with subsequent and later surgical treatment of the primary disease (megacolon).
A rare event is a patient with total fecaloma (a fecaloma which extends in continuity from the rectum to the cecum). Another rare event is a long chronic fecaloma (Fig. 25.9). Both of these lesions can cause pressure necrosis/ischemia followed by a stercoral ulcer. Stercoral perforation causes severe peritonitis. In 533 cases of patients with Chagasic megacolon at our institution, we reported an incidence of fecaloma of 43%.
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