Riesenkotsteine bei habitueller obstipation

History and findings: A 17-year old adolescent with chronic constipation developed fecal incontinence with liquid, fetid stool. He had had variable bowel symptoms since early childhood, but not in his infancy. Since several years he had undergone psychotherapeutic treatment for depression due to a familial conflict situation. Abdominal palpation revealed the presence of a large, hard mass in the lower abdomen, measuring about 20 cm in diameter. Investigations: A defecography verified the presence of a huge obstructing fecolith in the rectum, with massive dilation and elongation of the anteceding rectum and colon (megarectum and megacolon). Neither endoscopy nor radiological imaging revealed a narrow bowel segment. In sequential biopsies, no indication of aberrant innervation was found. The recto-anal inhibitory reflex could be elicited. Treatment and course: Restoration of the rectal passage was achieved by manual disimpaction in numerous sessions, supported by repeated rectal klysmas. Subsequently, the patient had normal daily bowel movements for a few days. However, he had to be readmitted three weeks later because again a fecolith had formed, measuring 15 cm in diameter. A few days after discharge the patient hat not followed the exhortation to void ad least once per day. After renewed disimpaction he was referred to a psychosomatic clinic. Conclusion: Voluntary withholding of defecation can eventuate massive coprostasis and the development of megacolon and megarectum. In theses instances the major complaint may not be constipation but paradoxical diarrhea. A number of conditions have to be excluded before the diagnosis idiopathic megacolon can be confirmed. Treatment is difficult and often necessitates prolonged and repetitious interventions.