A seven-year-old Japanese boy was presented with severe abdominal pain and vomiting. The patient had otherwise been well until he developed constipation at three years of age. One month before the current visit, he took a one-week domestic trip with his family. Since then, he had been constipated and visited physicians because of abdominal pain and was treated with glycerine enemas and laxatives. Thereafter, he only demonstrated watery stool. The patient had no history of Hirschsprung disease, abdominal surgery or the frequent use of anticholinergics or narcotics.

On examination, his abdomen was flat and bowel sounds were present. There was a large hard mass in his lower abdomen with tenderness, although there was no guarding or rebound tenderness. The edge of the mass was also smooth and palpable on a rectal digital examination. A plain X-ray of the abdomen obtained showed a large, round mass with laminar contents in the pelvis. (Figure 1) Flexible coloscopy revealed a large fecal ball (fecaloma) in the upper rectum with a normal mucosal membrane. (Figure 2) The next day, the patient was admitted to our hospital to remove the fecaloma under general anesthesia. It was too hard to crush colposcopically, and therefore, we had to press and crush it externally and finally remove it manually. The restored fecaloma was a cannonball-like shape measuring 6×10 cm in diameter and weighing 260 g. Thereafter, the patient showed a good recovery and had normal bowel movements every day. He had been in good condition for more than one year.

Fecal impaction sometimes grows into a hard and laminated large mass known as a fecaloma which may present features of acute gastrointestinal tract pain or mimic a carcinoma. Patients with fecaloma tend to have underlying conditions such as being elderly, having experienced previous abdominal surgery or having abused drugs (e.g., anticholinergics or narcotics). Although there have been a few reports concerning fecaloma in children complicated with encopresis, cerebral palsy, or Hirschsprung disease, reports of children with giant fecaloma with no underlying diseases are rare. [1] [2]

Fecal impaction in the rectum often becomes difficult and painful to evacuate in a constipated child. Therefore, more retention occurs and a vicious cycle is accomplished. [3] Patients with fecaloma often present with abdominal pain and discomfort, vomiting, and weight loss. Interestingly, overflow diarrhea tends to sometimes be observed in such patients because the liquid stool is evacuated by the movement of the colon through a void between the fecaloma and the colonic wall, as was observed in our patient. As the large hard mass is usually palpable in the abdomen in almost all patients, fecaloma may sometimes be confused with a colonic malignancy. [4] [5] It is not so difficult to accurately diagnose fecaloma, however, if one notes the characteristic features of plain abdominal X-rays which normally suggest laminar components with fecal impaction.

Finally, balanced diet that includes fruits, vegetables and liquids is recommended as a fundamental management of constipation in children. Low fiber intake has been shown to be a risk factor for chronic constipation. Carbohydrates in prune, pear and apple juices may increase water content in stools. [6] Caretakers should be aware of the dietary modification for their children who have hard bowel movements.

Clinicians should therefore be aware that fecal impaction can grow into a giant fecaloma even in a healthy child. Furthermore, a detailed history and a plain X-ray can provide important diagnostic clues in such patients.

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3. Sreedharan R, Liacouras CA. Major symptoms and signs of digestive tract disorders. In: Kliegman RM, et al., editors. Nelson Textbook of Pediatrics. 19th ed. Philadelphia: Elsevier; 2011. p. 1240–51.    
4. Rajagopal A, Martin J. Giant fecaloma with idiopathic sigmoid megacolon: report of a case and review of the literature. Dis Colon Rectum 2002 Jun;45(6):833–5.   [CrossRef]   [Pubmed]    
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