Authors: Surya Raj Nishad, Alisha Kusatha, Sushil Mishra, Sandesh Doranga, Sujan Shrestha, Pradeep Ghimire
Categories: Case Series, Intestinal obstruction, Small intestine, Faecal impaction, Operative surgical procedure, Case series
Source: International Journal of Surgery Case Reports
Authors: Surya Raj Nishad, Alisha Kusatha, Sushil Mishra, Sandesh Doranga, Sujan Shrestha, Pradeep Ghimire
Intestinal obstruction is a common surgical emergency; however, faecolith-induced obstruction is exceptionally rare, especially in the small intestine. This case series highlights an uncommon etiology of small bowel obstruction(SBO), with an emphasis on diagnostic challenges, surgical management, and patient outcomes.
We report three cases of SBO due to faecolith two geriatric and one pediatric patient. All presented with symptoms of abdominal distention, colicky pain, and failure to pass stool. Imaging, particularly contrast-enhanced computed tomography (CECT) of abdomen and pelvis revealed dilated small bowel loops with transition point and intraluminal hyperdense masses suggestive of faecolith-induced SBO, including one case of secondary small bowel obstruction due to a caecal faecolith. Emergency Surgical interventions included enterotomy in two cases and cecotomy in one, with one patient requiring a loop ileostomy due to bowel edema. All patients recovered uneventfully and were discharged between postoperative day (POD) 5 to 8.
Faecolith-induced SBO is an uncommon but important differential diagnosis, particularly in patients with no prior history of abdominal surgery. In such case early imaging with CECT is crucial for diagnosis. Timely and appropriate surgical intervention results in excellent outcomes and helps prevent complications such as ischemia or perforation.
Clinicians should maintain a high index of suspicion for faecolith-induced SBO in patients with typical features of bowel obstruction but no history of prior abdominal surgery. Prompt diagnosis and operative management can lead to favorable outcomes.
Small bowel obstruction (SBO) is the most common form of mechanical intestinal obstruction, accounting for nearly 15 % of emergency hospital admissions due to acute abdominal pain. In adults, the predominant culprit remains postoperative adhesions, responsible for approximately 60–75 % of cases, followed by neoplasms (5–20 %) and hernias (2–10 %) [1]. In the pediatric population, although adhesions remain common, intussusception accounts for 20–34 % of cases. Other significant causes include congenital anomalies such as small bowel atresia, malrotation, Meckel's diverticulum and volvulus [2].
Among the less common causes, faecoliths which are concretions of inspissated faecal matter that typically lodge in the rectum or sigmoid colon are widely recognized in large bowel pathology. These can follow a dramatic clinical course, occasionally resulting in life-threatening complications like obstruction, colonic perforation and faecal peritonitis [3]. Yet, in the vast spectrum of bowel obstruction, faecolith-induced small bowel obstruction remains an exceptional rarity. Only a few cases have been reported that dot the literature, making each report a valuable window into a seldom-encountered clinical entity that challenges diagnostic and surgical judgment [4].
We present a case series of three patients with SBO caused by faecoliths located in the ileum and caecum, including one case of secondary SBO due to caecal faecolith; all of whom were managed surgically with favorable outcomes. This case series aims to raise clinical awareness of this rare cause of SBO and to contextualize our findings through a comparison with previously published literature.
This case series has been reported in accordance with PROCESS 2025 guideline [5].
The cases were selected retrospectively from the records of patients admitted to relevant clinical department at our tertiary care center between January 2022 and April 2025. Inclusion criteria included patients of any age presenting with symptoms and imaging suggestive of small bowel obstruction who were intraoperatively confirmed to have faecolith-induced obstruction.
These cases were selected because faecolith-induced small bowel obstruction is extremely rare, particularly in patients with no prior abdominal surgery or chronic constipation. The aim was to highlight the diagnostic challenges, surgical approaches, and outcomes in this uncommon clinical scenario.
Demographic data, presenting symptoms, imaging findings, operative findings, and postoperative outcomes were collected from medical records and operative notes. Follow-up data were retrieved from outpatient records and direct communication with patients or their families.
Patient summary table (Table 1):
Table 1Clinical and surgical details of patients with faecolith-induced intestinal obstruction.Table 1CaseAge/SexSymptomsImagingLocationProcedureOutcome18/MAbdominal distention, pain, bilious vomiting, inability to pass stool/flatus (4 days)X-ray: air-fluid levels, dilated bowel loopsCECT- Dilated loops of bowel with prominent valvulae conniventesIleum (~60 cm proximal to ICJ)Enterotomy with faecolith removal and closureUneventful, discharged on POD 5278/MAbdominal distention, pain, bilious vomiting, inability to pass stool/flatus (6 days)CECT: Dilated bowel loops with transition near ileo-caecal junction (ICJ)Ileum (~6 cm proximal to ICJ)Enterotomy, faecolith removal, loop ileostomyUneventful, discharged on POD 8384/FOn/off abdominal pain, distension, constipation (7 days)CECT: faecolith in caecumCaecum- Secondary SBOCecotomy with Faecolith removal and closureUneventful, discharged on POD 7
Timeline of events•Symptom onset occurred 3–7 days prior to admission.•Abdominal imaging was performed within 24 h of presentation•Emergency or elective laparotomy was undertaken within 1–2 days of admission•All patients were discharged between POD 5 and 8 following uneventful recovery.
An 8-year old male child (weight: 18 kg) presented with a 4 day history of abdominal distention, colicky abdominal pain, multiple episodes of bilious vomiting and inability to pass stool/flatus. He had been managed conservatively at another hospital prior to referral. There was no past operative history. On examination the patient was dehydrated and vital signs at presentation T 98.2 °F, HR 130 bpm, BP 100/60 mmHg, RR 18/min, SpO₂ 98 % (room air). The abdomen was distended and tender on palpation. Routine blood investigations revealed leukocytosis with predominant neutrophils. Key Hb 13.1 g/dL, WBC 13.2 × 10^3^/mm^3^, Neutrophils 85 %, Platelets 244 × 10^3^/mm^3^,Na 137 mmol/L, K 3.5 mmol/L, Creatinine 0.5 mg/dL (reference ranges in Table 2).Table 2References ranges of lab parameters.Table 2TestReference rangeHb13–17 g/dLWBC4–11 × 10^3^/mm^3^Neutrophils40–80 %Platelets150–400 × 10^3^/mm^3^Na135–145 mmol/LK3.5–5.1 mmol/LSerum creatinine0.31–1.00 mg/dLSerum urea10–45 mg/dL
Abdomen X-ray showed multiple air-fluid levels with dilated ileal and jejunal bowel loops (Fig. 1). CECT of abdomen and pelvis revealed dilated small bowel loops with prominent valvulae conniventes and collapsed large bowel (Fig. 2). The patient was managed with nasogastric decompression, intravenous antibiotics (ceftriaxone 50 mg/kg/day IV in 2 divided doses + metronidazole 7.5 mg/kg IV q8h), iv antiemetics (ondansetron 0.15 mg/kg IV q8h), and fluid resuscitation (0.9 % saline 20 mL/kg bolus then maintenance) according to body weight. With no signs of improvement patient underwent emergency laparotomy. Intraoperatively, distended ileal and jejunal loops were noted with transition point around 60 cm proximal to ICJ (Fig. 3). A hard intraluminal mass was palpated at the transition point (Fig. 4). Enterotomy revealed two faecoliths measuring 4 × 4 cm and 2 × 2 cm, respectively (Fig. 5). The proximal dilated bowel was decompressed through the enterotomy site, which was then closed with single-layer interrupted absorbable sutures. The postoperative course was uneventful, and the patient was discharged on POD 5.Fig. 1Abdomen X-ray a. Erect view showing multiple air-fluid level (arrow head) in the intestinal lumen b. Supine view showing dilated bowel loops (arrow head).Fig. 1Fig. 2Abdomen and Pelvis CE-CT a. Coronal view showing multiple dilated small bowel loops (red asterisk) with prominent valvulae conniventes, consistent with SBO b. Axial view showing dilated small bowel loops with air-fluid levels (red arrow head). c. Scout view of CT showing dilated bowel loops with prominent valvulae conniventes. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)Fig. 2Fig. 3Distended small bowel after laparotomy.Fig. 3Fig. 4Faecolith (black asterisk) traced at about 60 cm from ICJ.Fig. 4Fig. 5Both faecolith extracted out of bowel lumen after enterotomy L: size 4 × 4 cm S: size 2 × 2 cm.Fig. 5
A 78-year old male presented with a 6 day history of abdominal distention, colicky abdominal pain, multiple episodes of bilious vomiting and inability to pass stool/flatus. There was no relevant past medical and surgical history. The patient was thin built and vitals at presentation T 98.7 °F, HR 90 bpm, BP 130/60 mmHg, RR 20/min, SpO₂ 97 % (room air). The abdomen was distended and tender on palpation. All hernial orifices were intact. Key Hb 13.2 g/dL, WBC 9.8 × 10^3^/mm^3^, Neutrophils 74 %, Platelets 204 × 10^3^/mm^3^, Na 135 mmol/L, K 3.6 mmol/L, Urea 28 mg/dL, Creatinine 0.8 mg/dL (reference ranges in Table 2). CECT of abdomen and pelvis revealed dilated ileum and jejunum loops with transition point near ileocecal (IC) region, and a hyperdense intraluminal mass approximately 5 cm proximal to ICJ. Following nasogastric decompression, iv antibiotics (piperacillin–tazobactam 4.5 g IV q8h + metronidazole 500 mg IV q8h), iv antiemetics (ondansetron 4 mg IV q8h) and fluid resuscitation (Ringer's lactate 2 L over first 6 h, then adjusted based upon urine output), the patient underwent emergency laparotomy. Intraoperatively, grossly dilated ileal and jejunal bowel loops were observed with firm intraluminal mass approximately 6 cm proximal to ICJ (Fig. 6a). The mass was mobile and was gently milked to a more proximal segment approximately 20 cm proximal to ICJ, where an enterotomy was performed (Fig. 6b). A faecolith measuring 10 × 4 cm was extracted, and dilated bowel segment was decompressed through the enterotomy site (Fig. 7b). Due to marked bowel edema, the enterotomy site was brought out as a loop ileostomy from right iliac region. The patient had an uneventful recovery and was discharged on POD 8.Fig. 6a. Distended small bowel loops after laparotomy with hard intraluminal mass (black asterisk) b. Faecolith localized and enterotomy being performed.Fig. 6Fig. 7a. Faecolith (F) after enterotomy being squeezed out of lumen b. A large 10 × 4 cm faecolith (F) brought out of intestinal lumen.Fig. 7
An 84-year old female was admitted through emergency department with a diagnosis of secondary subacute small bowel obstruction due to a cecal faecolith. She had a 7 day history of intermittent abdominal distention, pain and constipation. There was no history of vomiting, and she was able to pass flatus. She had no prior surgical history. Vital signs at presentation T 99 °F, HR 86 bpm, BP 138/72 mmHg, RR 18/min, SpO₂ 98 % (room air). The abdomen was mildly distended, with tenderness and rebound tenderness noted in the right iliac region. Key Hb 12.8 g/dL, WBC 7.4 × 10^3^/mm^3^, Neutrophils 68 %, Platelets 200 × 10^3^/mm^3^, Na 138 mmol/L, K 3.7 mmol/L, Creatinine 0.9 mg/dL (reference ranges in Table 2). CECT abdomen and pelvis revealed large Faecolith at caecum with dilatated small bowel loops (Fig. 8). The patient was initially managed with iv fluids (Ringer's lactate 1 L over first 6 h then adjusted based upon urine output), iv antibiotics (ceftriaxone 1 g IV q12h + metronidazole 500 mg IV q8h) and nasogastric decompression. Due to failure of conservative treatment, she underwent elective operation via Gridiron incision. Upon entering the peritoneum, a hard mass was palpated at the caecum, along with an atrophied appendix and dilated small bowel loops. A cecotomy was performed, revealing 4 × 3 cm faecolith; an appendectomy was also carried out (Fig. 9). The cecotomy was closed in single layer using interrupted absorbable sutures. The postoperative course was uneventful, and she was discharged on postoperative day 7.Fig. 8Coronal view of abdomen and pelvis CE-CT showing faecolith inside caecum (red arrow head). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)Fig. 8Fig. 9Specimen showing 4 × 3 cm spherical faecolith (F) and atrophied appendix (A) with mesoappendix.Fig. 9
Bezoars were considered as a differential diagnosis both preoperatively and intraoperatively in all of our cases; However, several features supported the diagnosis of faecoliths. Intraoperatively, the obstructing masses were hard, dry, laminated, and clay-colored, lacking plant fibers, hair, or undigested food material typical of bezoars. On CECT, the lesions appeared as homogeneous hyperdense intraluminal masses, occasionally with peripheral calcification, without the mottled gas (“speckled”) pattern characteristic of bezoars. These morphologic and radiologic features, combined with the absence of dietary risk factors or psychiatric history, favored faecolith formation. Histopathological confirmation examination was not done.
All these patients in this case series underwent abdominal imaging with CECT that identified dilated loops, transition zones, and hyperdense intraluminal masses. Imaging was crucial in planning surgical management. Each case required surgical removal of faecoliths. One patient required a diverting loop ileostomy due to bowel edema. No resections were necessary. On follow-up (6 month), all patients recovered uneventfully. No complications or recurrences were noted during this period. Patients and guardians expressed relief at resolution of symptoms and satisfaction with the care received.
Faecolith formation is believed to result from a combination of reduced colonic motility, inadequate hydration, and a low-fiber diet. These factors contribute to prolonged stool transit time, leading to inspissation and eventual calcification of faecal matter leading to faecolith formation [6]. This is usually associated with underlying long-term constipation, Hirschsprung's disease, Chagas disease, inflammatory bowel diseases, cancers of the bowel, and certain psychiatric disorders [7]. However, none of the patients described in this case series had such predisposing conditions, making the suspicion of faecolith-induced SBO less likely preoperatively.
Although rare, intestinal faecoliths have been reported in pediatric population. A rare pediatric case of colonic obstruction due to a giant faecolith was reported by Su et al., where a 7-year-old child developed a 6 × 6 cm faecolith in the sigmoid colon following the ingestion of unshelled broad beans. Diagnosis was confirmed via CT and barium enema, and successful extraction was achieved through colonoscopy-assisted manual removal, highlighting the feasibility of minimally invasive management even in large faecoliths [8].
Dhulipala et al. reported a 76-year-old female with a 3-week history of crampy abdominal pain and constipation that acutely progressed to full obstruction with inability to pass flatus. Imaging revealed a high-grade SBO with a clear transition zone in the distal ileum. After 8 days of failed conservative management (NG decompression, hydration), she underwent exploratory laparotomy. Intraoperatively, a firm, intraluminal 3 cm faecolith was found with multiple strictures in the terminal ileum. These strictures strongly suggested that the bowel segment were chronically diseased, and therefore not viable for enterotomy and closure. As a result, 17 cm segmental resection with primary anastomosis was performed, and pathology confirmed inspissated stool. The patient recovered without complications [9].
Chen et al. (2022) reported a 66-year-old male who developed symptoms of abdominal pain, vomiting, and failure to pass flatus one day after consuming a large quantity of persimmons. Initial conservative management (fasting, IV fluids, GI decompression, antibiotics) failed to alleviate his symptoms over 2 days. Contrast-enhanced CT revealed an incomplete small bowel obstruction approximately 10 cm proximal to the ileocecal valve. Laparoscopic exploration identified a hard, cylindrical phytobezoar (≈2.5 × 3 cm), which was removed via enterotomy. The patient recovered well and was discharged on post-operative day 7 [14].
The comparison of faecolith-induced small bowel obstruction cases, including pediatric and adult patients, reveals a diverse clinical spectrum affecting a wide age range from children to elderly adults. Presentations commonly include abdominal pain, distention, and vomiting, although symptom onset can range from acute to subacute durations. Vital signs and physical examination findings vary, with some patients presenting dehydration or tender abdomens, while others have more subtle clinical signs.
Imaging modalities particularly abdomen and pelvis CECT, which is imaging modality of choice is pivotal in diagnosing faecoliths, delineating their size, location, and the degree of bowel obstruction. Typical CT findings include, Well-defined, hyperdense intraluminal masses consistent with faecoliths, often showing laminated or mottled calcifications [10], dilation of proximal small bowel loops with multiple air-fluid levels, indicating obstruction [9,10], a clear transition zone where bowel caliber abruptly changes from dilated to collapsed, localizing the obstruction site [11].CT may also identify associated complications such bowel wall thickening or signs of ischemia, which warrant urgent surgical intervention [10]. All three of our cases had preoperative imaging suggestive of obstruction, and CECT played a critical role in diagnosis.
Faecolith size in reported cases varies widely, ranging from 3 cm to 10 cm, and can be located anywhere from the ileum to the colon, including specialized sites such as the caecum or sigmoid colon. Operative findings consistently reveal hard intraluminal masses causing mechanical obstruction.
Surgical treatment remains the mainstay of management of these condition that predominantly involves enterotomy [10] which would follow laparoscopy [9] wherever feasible or laparotomy where either laparoscopy is not feasible due to poor visibility due to distended bowel loops [12,13] (This is especially important in cases where delayed presentation results in marked bowel distension) or possible due to its unavailability, financial constraints or other contradiction for faecolith extraction, with some cases necessitating bowel resection [9] or diversion procedures such as ileostomy(case 2). The need for bowel resection and anastomosis or stoma creation depends on bowel condition and intraoperative findings. In our case series, only one patient required a loop ileostomy due to grossly dilated and edematous bowel. Minimally invasive approaches, including colonoscopy-assisted removal [8], have been successful in selective pediatric patients. Postoperative courses across studies are uniformly favorable, with uneventful recoveries. The primary limitations of this study include the small number of cases and its retrospective, single-institution nature. These factors may limit generalizability.
Faecolith-induced SBO is a rare but important differential diagnosis, particularly in patients without prior abdominal surgery. This case series underscores the diagnostic challenges and surgical management of this uncommon entity. Radiologic imaging, especially contrast-enhanced CT, plays a pivotal role and surgical intervention typically via enterotomy or cecotomy with faecolith extraction is curative with favorable outcomes.
Take-away points•Rarity & Relevance: Faecoliths are rare causes of SBO, especially in the small intestine, and may occur in both pediatric and geriatric populations.•Imaging Utility: Contrast-enhanced CT is the modality of choice for diagnosis, reliably identifying transition points and intraluminal masses.•Surgical Management: Open surgical approaches, including enterotomy or cecotomy, are definitive; laparoscopy may be considered if bowel distension is not prohibitive.•Outcomes: All cases in this series recovered uneventfully postoperatively, reinforcing that timely intervention yields excellent results.•Clinical Awareness: Clinicians should consider faecoliths in the differential diagnosis of SBO in patients with no prior surgeries and typical presentation of intestinal obstruction.
1.Surya Raj Nishad - Conceptualization, Writing - Original Draft, Writing - Review & Editing, Project Administration.2.Alisha Kusatha - Conceptualization, Writing - Original Draft, Writing - Review & Editing, Project Administration.3.Sushil Mishra - Writing - Review & Editing, Supervision4.Sandesh Doranga - Writing - Review & Editing, Supervision5.Sujan Shrestha - Writing - Review & Editing, Supervision6.Pradeep Ghimire - Review & Editing, Supervision
All authors contributed to the manuscript, reviewed the final version, and approved it for submission.
Written informed consent was obtained from all patients and from legal guardian of the pediatric patient for publication of this case details and associated images. Copy of the signed consent is available for review by the Editor-In-Chief of this journal on request.
This case series was conducted using retrospective data that did not include any identifiable patient information or involve any experimental procedures. According to the policy of our institution, such studies are exempt from formal review by the ethics committee. However, permission to publish the cases was granted by relevant clinical department.
1.Surya Raj Nishad2.Alisha kusatha
The patient and their families expressed satisfaction with the rapid and complete recovery following surgical treatment.
Nothing to declare.
No funding was received for reporting this case series.
The authors declare no conflicts of interest related to this publication.