Fecal Impaction in the Emergency Department An Analysis of Frequency and Associated Charges in 2011 Caroline Corban, BA,* Thomas Sommers,* Neil Sengupta, MD,w Mike Jones, PhD,z Vivian Cheng, MS, MPH,* Elizabeth Friedlander, NP, PhD,* Andrea Bollom, BS,* and Anthony Lembo, MD* Goals: The aim of this study was to analyze the incidence and associated charges of fecal impaction for trends in hospital and patient demographics in emergency departments (ED) across the United States. Background: In 2010, an ICD-9-CM code (560.32) for fecal impaction was introduced, allowing for assessment of fecal impaction incidence. Study: Data were obtained from the National Emergency Department Sample records in which fecal impaction (ICD-9-CM code 560.32) was first listed as a diagnosis in 2011. Results: In 2011, there were 42,481 [95% confidence interval (CI), 39,908-45,054] fecal impaction ED visits, with an overall rate of 32 fecal impaction visits per 100,000 ED visits. Adjusted for inflation in 2014 dollars, the associated mean charge of a fecal impaction ED visit was $3060.47 (95% CI, $2943.02-$3177.92), with an aggregate national charge in the US of $130,010,772 (95% CI, $120,688,659- $139,332,885). All charges were adjusted for inflation and reported in 2014 dollars. Late elders (85 + y) had the highest rate of fecal impaction ED visits, followed by early elders (65 to 84 y). Medicare was the primary payer for the greatest number of fecal impaction ED visits accounting for nearly two thirds of visit payments. Conclusion: This study reports previously unexplored statistics on the number, frequency, and associated charges of ED visits with a primary diagnosis of fecal impaction, a condition found most commonly among elders. Key Words: fecal impaction, emergency department, hospital charges (J Clin Gastroenterol 2015;00:000–000) F ecal impaction is defined as the inability to pass large, hardened stools through the rectum or lower colon. 1 It is diagnosed in the clinical setting either through rectal examination or x-ray. Fecal impaction is found more commonly in the elderly, particularly in those with medical comorbidities such as Alzheimer disease, Parkinson disease, dementia, stroke, and in persons who are bedridden. 1,2 The exact incidence of fecal impaction is unknown, although it appears to be especially common among hospitalized patients. 2,3 A retrospective study from a single tertiary medical center in Lebanon found 0.7% of hospital admis- sions were due to fecal impaction, 2 whereas in a geriatric hospital ward, fecal impaction has been found in up to 42% of patients. 4 Fecal impaction is often a recurring problem in patients, as shown in 1 study in which 39% of patients reported a prior history of fecal impaction. 5 The symptoms associated with fecal impaction are often nonspecific, making the diagnosis challenging. The symptoms include worsening constipation, diarrhea, abdominal pain, bloating, fecal and urinary incontinence, anorexia, nausea, vomiting, and weight loss. In this study, fecal impaction was diagnosed by ICD-9 code when listed as the primary diagnosis. The diagnosis can be particularly challenging in patients with paradoxical diarrhea or overflow incontinence and in patients who are unable to adequately describe their symptoms. 6 Fecal impaction has been found in 20% of institutionalized individuals with fecal incontinence, 7 25% of elderly nursing home residents with urinary dysfunc- tion, 8 and 55% of permanently hospitalized patients with diarrhea. 9 When suspected, a digital rectal examination or an abdominal x-ray can assist in making the diagnosis of fecal impaction. 1 Fecal impaction can lead to serious life-threatening complications 6 especially in young children and late elderly patients. 10,11 One of the most serious and acute complica- tions of fecal impaction is perforation from stercoral ulceration or distention of the bowel lumen. 1,12 One study reported a mortality rate of 34% from stercoral perfo- ration. 13 Less common complications of fecal impaction include pneumothorax from straining, volvus, autonomic dysreflexia, hepatic encephalopathy, dysfunctional labor, rectal prolapse, shock from loss of fluid into the bowel, and hypoxia. 14,15 Fecal impaction is generally treated by digital fragmentation, mechanical disimpaction, oral or rectal washout (eg, oral laxatives or enema), and in rare cases, surgery. 2,16 Despite its clinical significance, many patients remain undertreated. In a nursing home study, 26.4% of patients with fecal impaction who reported constipation were undertreated, despite available treatment options. 17 The aim of this study was to analyze the incidence, frequency, and associated charges of fecal impaction for trends in hospital and patient demographics in emergency departments across the United States. This study will pro- vide valuable information on the prevalence and economic burden of this disabling gastrointestinal condition, encour- aging advances in its diagnosis, prevention, and treatment. Received for publication April 6, 2015; accepted November 2, 2015. From the *Division of Gastroenterology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA; wDivision of Gastroenterology, Department of Medicine, University of Chicago, Chicago, IL; and zDepartment of Psychology, Macquarie Uni- versity, Sydney, NSW, Australia. The authors declare that they have nothing to disclose. Reprints: Anthony Lembo, MD, Division of Gastroenterology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 (e-mail: alembo@bidmc.harvard.edu). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. ORIGINAL ARTICLE J Clin Gastroenterol  Volume 00, Number 00, ’’ 2015 www.jcge.com | 1 Copyright r 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.