March 26, 2008
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Full of It
DISCLAIMER: THIS POST IS NOT FOR THE SQUEAMISH AS IT CONTAINS MANY MANY USES OF THE WORD, POOP. THANK YOU.
Ah into the wonderful world of pediatrics, where a sense of smell can definitely hamper your ability to effectively practice medicine.
My first patient was a 10yr old male with a 7 year history of ADHD, and fecal incontinence with soiling (pooping his pants unexpectedly) He had been a normal vaginal birth, met all appropriate developmental milestones, including toilet training, when suddenly about age 3, the mother noticed he would simply have uncontrollable bowel movements and soil himself. SThis happened every day, with approximately 2 of his 4 bowel movements per day, where the pt would feel the urge to go, and then defecate before having enough time to make it to a restroom. Stools had no blood, and were normal in color and consistency. She then took him to several doctors, all who told her he was doing it for attention until she finally reached our hospital where we decided to take a closer look.
On physical exam, the pt was an active cooperative male child. Vitals were within normal limits and physical exam was uneventful except for a hard mass in the right lower quadrant and suprapubically
Our working diagnosis is encopresis with fecal impaction and constipation.
So you may be wondering how one can be constipated for 7 years, and soiling their shorts at the same time. Or maybe you just dont know what encopresis is…
Basically, at some point in his development (probably a little before age 3) poop started to build up in his colon, as in he was not dropping all the kids off at the pool, but leaving a few in the van. Now the colon serves to remove water and bicarb from your digested food, leaving behind a mostly solid mass of unusable nutrients (aka poop). As the years went buy, the undefecated poop continued to back up and have even more water removed from it basically turning it from a log into a tree. Or more specifically, that mass felt in the abdomen was solid poop backed up all the way into his gut. This was confirmed by x-ray
This kid was quite literally, full of shit
So the plan? First, laxatives and enemas. Not because either of these will clean out seven years worth of congealed poo by itself, but it will soften the stool up and clear out some loose pieces as he is prepared for …DISIMPACTION.
Ah yes, disimpaction, where the pt is sedated with ketamine (pain control) and midazolam (relaxation and slight amneistic effects) as some lucky resident or medical student gets to reach a couple fingers into the rectum and scoop out the fecal matter bit by bit, with another hand on the stomach to move that log down as it is continuously dug out.
Sadly, (and i really mean this) I could not stay to observe or assist, as i had to go to a lecture
but the most disturbing part of this whole case?
How in the world is a 3 year old diagnosed with ADHD?
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Why Not Zoidberg
Comments (7)
I believe one and all must glance at it.
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I meant “not” a 7-year-old, but more like a 70-year-old.
and did I mention this was an elderly person, 7-year-old. Somehow, disimpacting a child doesn’t feel quite as icky. Is that wrong?
What’s worse is when, after the intern before you signs out that a patient has not had a bm in several days and that an enema should be tried, you check the patient’s behind only to discover that there is literally stool hanging out of the rectum and that neither the intern on the entire day or the nurse ever bothered to check down there, and now it becomes the responsibility of you (the unlucky intern, a.k.a. Gen) to manually disimpact the patient simply because nobody ever bothered to check the area when it was probably more disimpactable and less nauseating to begin with.
That is really, really gross. And it seems like after 7 years, his poop tree would have had nowhere left to grow…right? I mean, maybe I just poop more than the average young boy, and maybe I don’t know anything about the human body, but I feel like he’d have poop comin’ out the mouth!
I wonder how this could be going on for 7 years? Maybe the parents thought it was just a phase, but one that lasts 7 years? yikes. I hope that little boy will be doing better soon. That’s got to be embarassing for him always pooping in his pants.
poor kid. poor med student!
i think youll really love peds- just a feeling. hopefully no more poopy adhd children though.