Case synopsis

A 70-year-old man with a history of severe chronic psychosis treated with olanzapine was admitted to the emergency department for acute abdominal pain. He reported the absence of stools for 3 weeks together with an increasing abdominal perimeter. The patient developed severe arterial hypotension requiring ICU admission for vasopressor support. Upon ICU admission, the patient had a severely distended abdomen with a diffuse collateral venous circulation (Fig. 1). There was no clinical sign of ascites nor spider angioma. Laboratory tests revealed hyperlactatemia (6.7 mmol/L, N < 1.6 mmol/L) and acute kidney failure (creatinine 185 μmol/L, N < 110 μmol/L) with anuria.

Fig. 1
figure 1

Abdominal distension and diffuse collateral venous circulation

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Diagnosis

Abdominal computed tomography depicted a severe fecal impaction (Fig. 2) with a marked backward compression of the kidneys (Fig. 3, white arrow) together with a peritoneal effusion (Fig. 3, ***). There were no signs of pneumoperitoneum, bowel pneumatosis, or parietal thickening. Because of the previous limited autonomy of the patient with cognitive decline, a conservative strategy without surgical extraction of the fecaloma was decided. The patient eventually died on day 2.

Fig. 2
figure 2

Saggital (left) and coronal (right) views of the abdominal computed tomography revealing a severe fecal impaction

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Fig. 3
figure 3

Axial view of the abdominal computed tomography revealing a marked backward compression of the kidneys (white arrow) together with aperitoneal effusion (***)

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Chronic constipation with fecal impaction is a well-known complication of long-term neuroleptic treatment [1, 2]. Severe forms may be life-threatening [3, 4] and may require an emergency laparotomy [5] before the onset of intraabdominal complications. In this context, prevention with systematic administration of laxatives appears of paramount importance.