Breath with fecal odor
Breath with fecal odor: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Fecal breath odor typically accompanies fecal vomiting associated with a long-standing intestinal obstruction or gastrojejunocolic fistula. It represents an important late diagnostic clue to a potentially life-threatening GI disorder because complete obstruction of any part of the bowel, if untreated, can cause death within hours from vascular collapse and shock.
When the obstructed or adynamic intestine attempts self-decompression by regurgitating its contents, vigorous peristaltic waves propel bowel contents backward into the stomach. When the stomach fills with intestinal fluid, further reverse peristalsis results in vomiting. The odor of feculent vomitus lingers in the mouth.
Fecal breath odor may also occur in patients with a nasogastric (NG) or intestinal tube. The odor is detected only while the underlying disorder persists and abates soon after its resolution.
Emergency interventions
Because fecal breath odor signals a potentially life-threatening intestinal obstruction, you’ll need to quickly evaluate your patient’s condition. Monitor his vital signs, and be alert for signs of shock, such as hypotension, tachycardia, narrowed pulse pressure, and cool, clammy skin. Ask the patient if he’s experiencing nausea or has vomited. Find out the frequency of vomiting as well as the color, odor, amount, and consistency of the vomitus. Have an emesis basin nearby to collect and accurately measure the vomitus.
Anticipate possible surgery to relieve an obstruction or repair a fistula, and withhold all food and fluids. Be prepared to insert an NG or intestinal tube for GI tract decompression. Insert a peripheral I.V. line for vascular access, or assist with central line insertion for large-bore access and central venous pressure monitoring. Obtain a blood sample and send it to the laboratory for complete blood count and electrolyte analysis because large fluid losses and shifts can produce electrolyte imbalances. Maintain adequate hydration and support circulatory status with additional fluids. Give a physiologic solution—such as lactated Ringer’s or normal saline solution or Plasmanate—to prevent metabolic acidosis from gastric losses and metabolic alkalosis from intestinal fluid losses.
History and physical examination
If the patient’s condition permits, ask about previous abdominal surgery because adhesions can cause an obstruction. Also ask about loss of appetite. Is the patient experiencing abdominal pain? If so, have him describe its onset, duration, and location. Ask if the pain is intense, persistent, or spasmodic. Have the patient describe his normal bowel habits, especially noting constipation, diarrhea, or leakage of stool. Ask when the patient’s last bowel movement occurred, and have him describe the stool’s color and consistency.
Auscultate for bowel sounds; hyperactive, high-pitched sounds may indicate an impending bowel obstruction, whereas hypoactive or absent sounds occur late in obstruction and paralytic ileus. Inspect the abdomen, noting its contour and any surgical scars. Measure abdominal girth to provide baseline data for subsequent assessment of distention. Palpate the abdomen for tenderness, distention, and rigidity. Percuss it for tympany, indicating a gas-filled bowel, and dullness, indicating fluid.
Rectal and pelvic examinations should be performed. All patients with a suspected bowel obstruction should have a flat and upright abdominal X-ray; some will also need a chest X-ray, sigmoidoscopy, and a barium enema.
Medical causes
Gastrojejunocolic fistula
Symptoms of gastrojejunocolic fistula may be variable and intermittent because of temporary plugging of the fistula. They may include fecal vomiting with resulting fecal breath odor, but the chief complaint is usually diarrhea accompanied by abdominal pain. Related GI findings include anorexia, weight loss, abdominal distention, and possibly marked malabsorption.
Large-bowel obstruction
Vomiting is usually absent at first, but fecal vomiting with resulting fecal breath odor occurs as a late sign. Typically, symptoms develop more slowly than in small-bowel obstruction. Colicky abdominal pain appears suddenly, followed by continuous hypogastric pain. Marked abdominal distention and tenderness occur, and loops of large bowel may be visible through the abdominal wall. Although constipation develops, defecation may continue for up to 3 days after a complete obstruction because of stool remaining in the bowel below the obstruction. Leakage of stool is common in a partial obstruction.
Small-bowel obstruction, distal
In late obstruction, nausea is present but vomiting may be delayed. Vomitus initially consists of gastric contents, then changes to bilious contents, followed by fecal contents with resulting fecal breath odor. Accompanying symptoms include achiness, malaise, drowsiness, and polydipsia. Bowel changes (ranging from diarrhea to constipation) are accompanied by abdominal distention, persistent epigastric or periumbilical colicky pain, hyperactive bowel sounds, and borborygmus. As the obstruction becomes complete, bowel sounds become hypoactive or absent. Fever, hypotension, tachycardia, and rebound tenderness may indicate strangulation or perforation.
Special considerations
After an NG or intestinal tube has been inserted, keep the head of the bed elevated at least 30 degrees and turn the patient to facilitate passage of the intestinal tube through the GI tract. Don’t tape the intestinal tube to the patient’s face. Ensure tube patency by monitoring drainage and checking that suction devices function properly. Irrigate as required. Monitor GI drainage, and send serum specimens to the laboratory for electrolyte analysis at least once a day. Prepare the patient for diagnostic tests, such as abdominal X-rays, barium enema, and proctoscopy.
Pediatric pointers
Carefully monitor the child’s fluid and electrolyte status because dehydration can occur rapidly from persistent vomiting. The absence of tears and dry or parched mucous membranes are important clinical signs of dehydration.
Geriatric pointers
In older patients, early surgical intervention may be necessary for a bowel obstruction that doesn’t respond to decompression because of the high risk of bowel infarct.
Patient counseling
Encourage the patient to brush his teeth and gargle with a flavored mouthwash or a half-strength hydrogen peroxide mixture to minimize offensive breath odor. Assure him that the fecal odor is temporary and will abate after treatment of the underlying cause.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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