Introduction
Fecal impaction (FI) is a condition characterized by the formation of large, hard fecal masses in the lumen of the large intestine, which cannot be expelled naturally. This condition predominantly affects older adults but can also occur in children or patients with neuropsychiatric disorders.
FI leads to numerous complications. The development of hard fecal masses may cause mechanical obstruction of the colonic lumen and elevate intraluminal pressure, potentially resulting in ischemia, ulceration, and perforation of the colonic wall. Additionally, these masses compress surrounding nerves, blood vessels, and organs, contributing to further complications [1]. A mortality rate of 30% has been reported due to associated complications [2].
This report describes two forensic autopsy cases of FI in patients with neuropsychiatric disorders. Although FI is well documented in older adults and individuals with disabilities, this report emphasizes its fatal consequences in younger patients with neuropsychiatric conditions.
Case Report
1. Case 1
The deceased, a 52-year-old man with mild intellectual disability, entered a room after bathing at approximately 07:30 and was later found unconscious by a family member. He had been receiving neuropsychiatric treatment and prescribed medications for approximately 30 years. According to family testimony, diarrhea began the day before his death and persisted until the following morning.
An autopsy was performed 2 days postmortem. The deceased measured approximately 173 cm in height with a thin physique. Reddish-purple livor mortis was observed on the back, and an external examination revealed abdominal distension (Fig. 1A).
Internal examination disclosed sternal and rib fractures attributed to cardiopulmonary resuscitation. The rectum, sigmoid colon, descending colon, and transverse colon exhibited marked dilation (maximum diameter exceeding 10.0 cm), accompanied by ischemic changes in the colonic wall. The lumens of the sigmoid and descending colons were obstructed by a substantial mass (approximately 2,200 g or more) of hard feces (Fig. 1B-D). No evidence of bowel perforation or septic shock was identified. Examination of other internal organs revealed no abnormal findings indicative of an alternative cause of death.
Toxicology testing detected no specific toxic substances, with an ethyl alcohol concentration below 0.010%.
2. Case 2
The deceased, a 25-year-old man with severe intellectual disability, was discovered deceased by his father while sleeping in a living room. He had been prescribed neuropsychiatric medications, and family members reported diarrhea beginning 4 days prior to death. The night before, he consumed porridge and medication before falling asleep.
An autopsy was performed 2 days postmortem. The deceased measured approximately 172 cm in height with a thin physique. Reddish-purple livor mortis was noted on the back. External examination identified no abnormalities beyond a yellow foreign body near or within the mouth.
Internal examination revealed a total length of 113 cm for the rectum, sigmoid colon, and descending colon, with a maximum diameter of approximately 12.0 cm. Significant dilation was observed, and the lumens of these segments were obstructed by a large quantity of hard feces. No evidence of bowel perforation or septic shock was found. Additionally, no abnormal findings that could be considered the cause of death were observed in other internal organs (Fig. 2A, B).
Toxicology testing of blood and gastric contents detected antipsychotic agents (risperidone and quetiapine) and a Parkinson's syndrome medication (benztropine) within therapeutic ranges, with no specific toxic substances identified. The ethyl alcohol concentration was below 0.010%.
Based on these findings, the cause of death in both cases was determined to be mechanical intestinal obstruction resulting from massive FI.
Discussion
FI affects individuals across all age groups but is particularly prevalent among older adults in care facilities, children, and patients with disabilities or neuropsychiatric disorders. Patients with neuropsychiatric disorders are especially susceptible due to inactivity, neglect of bowel habits, and autonomic dysfunction, such as parasympathetic hypofunction [3]. These factors frequently contribute to chronic constipation, megacolon, and megarectum, conditions worsened by the parasympatholytic effects of medications including antipsychotics, tricyclic antidepressants, and antiparkinsonian drugs [4]. The combination of neuropsychiatric conditions and medication-induced gastrointestinal effects predisposes these patients to severe complications, including FI.
Clinical symptoms of FI—such as abdominal pain, distension, anorexia, and diarrhea—are often nonspecific and may be overlooked in patients with neuropsychiatric disorders [5]. In the two cases reported, loose stools were observed prior to death in both patients, a paradoxical yet common symptom of FI resulting from liquid stools bypassing impacted feces. Misinterpretation of this symptom can lead to inappropriate treatment, as antidiarrheal medications may exacerbate the obstruction.
Beyond mechanical obstruction, the systemic effects of FI pose life-threatening risks. Severe colonic dilation increases intra-abdominal pressure, potentially causing abdominal compartment syndrome (ACS), which impairs systemic circulation and organ perfusion [6]. Excessive colonic distension may also stimulate the vagus nerve, triggering severe bradycardia and cardiovascular collapse. Furthermore, prolonged intestinal stasis disrupts electrolyte homeostasis, often leading to potassium imbalances that precipitate fatal arrhythmias [7]. These mechanisms demonstrate that FI can independently cause death, even without bowel perforation or sepsis.
Although rare, FI remains a critical consideration in forensic medicine. Differentiation from Ogilvie syndrome (acute colonic pseudo-obstruction), which involves colonic dilation without mechanical obstruction in critically ill patients, is essential. In contrast, FI results from physical blockage by hardened feces, frequently leading to megacolon, ischemic changes, and perforation.
Forensic examination of FI should evaluate the extent of colonic dilation, ischemic damage, and obstruction. In the reported cases, significant dilation of the rectal and sigmoid colonic, thinning of the intestinal wall, and ischemic mucosal changes were observed in both patients, though no perforations were present. Given the absence of bowel perforation, death was attributed to systemic complications of FI, including circulatory compromise and fatal arrhythmias. Forensic investigations should also assess systemic impacts, such as ACS-related circulatory compromise, vagal reflex-induced cardiac inhibition, and electrolyte disturbances contributing to arrhythmias [7]. These factors must be analyzed to determine whether death resulted solely from mechanical obstruction or from secondary systemic effects. Therefore, forensic evaluation should encompass both mechanical obstruction and associated systemic complications, including ACS, vagal reflex-induced cardiac inhibition, and fatal arrhythmias.
Given the elevated risk of FI in patients with neuropsychiatric disorders, forensic pathologists must remain vigilant in recognizing these mechanisms when establishing the cause of death. Comparative analysis of forensic and clinical findings from previous cases can offer valuable insights into diagnostic challenges and risk factors associated with FI. Table 1 compares findings from the present cases with previous literature to enhance understanding of the clinical and forensic aspects of FI.
From a legal and ethical standpoint, FI in institutionalized or neuropsychiatric patients raises concerns about medical negligence and care quality. In deaths occurring in hospitals or care facilities, forensic evaluation should ascertain whether appropriate interventions were attempted and whether contraindicated medications, such as antidiarrheals, were administered. Additionally, neglect or abuse—including malnutrition, dehydration, or pressure ulcers—must be excluded, particularly in vulnerable populations such as individuals with intellectual disabilities or neuropsychiatric conditions.
In the present cases, no evidence of external trauma, dehydration, malnutrition, or neglect was identified. Both patients had long-standing neuropsychiatric disorders, yet no signs of abuse or forced restraint were observed. These findings suggest that FI represents a preventable medical event rather than a consequence of intentional neglect.
Recognition and management of gastrointestinal symptoms in patients with neuropsychiatric disorders are often delayed due to communication barriers, reduced symptom awareness, and limited healthcare access. The interaction between neuropsychiatric medications and gastrointestinal motility underscores the need for proactive bowel management. Routine monitoring of bowel habits, early intervention, and avoidance of inappropriate medications, such as antidiarrheals, in undiagnosed FI cases is essential.
Multidisciplinary collaboration among psychiatrists, primary care physicians, and gastroenterologists can facilitate identification of high-risk patients and implementation of preventive protocols. Caregiver education is equally vital, particularly for older adults and patients with neuropsychiatric disorders, who are most susceptible to FI complications. Studies, such as those by Falcón et al. [2], indicate that older adults and patients with neuropsychiatric disorders constitute the majority of FI cases, emphasizing the importance of vigilant care and prevention strategies.
FI represents a preventable, yet potentially fatal condition in patients with neuropsychiatric disorders. Forensic pathologists must thoroughly evaluate the differential diagnoses, pathological findings, and legal considerations when determining the cause of death. Early recognition of warning signs, such as paradoxical diarrhea, can avert fatal outcomes. Systematic monitoring, caregiver education, and prompt medical intervention can significantly reduce the morbidity and mortality associated with FI in vulnerable populations.
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