Acute Kidney Injury Secondary to Fecaloma: A Rare Complication of Chronic Constipation

CASE REPORT An 86-year-old woman with chronic kidney disease, heart failure, cerebral amyloid angiopathy, diverticulosis, and a 4-year history of constipation presented with worsening lower extremity edema and 15-pound weight gain despite diuretic adherence. Her last bowel movement 2 days before presentation consisted of small, hard stool. Physical examination revealed a distended abdomen and 4+ bilateral lower extremity edema. Creatinine on admission was 1.30 (baseline 0.90), suggesting an acute kidney injury (AKI). Diuresis for suspected acute decompensated heart failure did not improve renal function. Computed tomography imaging demonstrated severe dilation of the rectum and sigmoid colon from impacted stool (Figure 1), a dilated gastric lumen (Figure 2), 180-degree spleen rotation (Figure 3), and mild bilateral hydronephrosis from extrinsic ureteral compression (Figure 4). Initial management with manual disimpaction and an escalating regimen of polyethylene glycol, senna, bisacodyl, and mineral oil enemas was unsuccessful. Ultimately, the patient underwent an examination under anesthesia with disimpaction of over 2 L of stool and resolution of obstruction and AKI. Discharge medications included linaclotide, oral bisacodyl, senna, and as-needed mineral oil enemas. Despite being extremely rare, fecal impaction with extrinsic renal and ureteral compression should be considered as a potential cause of an AKI in patients with chronic constipation.Figure 1.: Sigmoid colon and rectum dilation due to impacted stool (arrow) measuring up to 36.5 cm in the sagittal plane.Figure 2.: Axial computed tomography image demonstrating distension of the gastric lumen and fluid contents (arrow) due to compression of the greater curvature of the stomach by sigmoid colon dilation.Figure 3.: Coronal computed tomography image showing spleen rotation of approximately 180 degrees (arrow) due to extrinsic compression.Figure 4.: Coronal computed tomography image showing bilateral hydronephrosis (arrows), more prominent on the right than the left, due to extrinsic compression of the ureters by a dilated sigmoid colon and rectum.DISCLOSURES Author contributions: Both authors conceptualized the work, gave approval of the final version, and accept accountability for the published material. E. Almazan wrote the initial draft and participated in revisions. E. Petersen revised the initial draft. E. Almazan and EM Petersen are the guarantors of the article. Financial disclosure: None to report. Informed consent was obtained for this case report.