A 76-Year-Old Man Is Brought to the Office for Evaluation

A 76-year-old man is brought to the office for evaluation of fecal incontinence.  The patient has a history of lung cancer metastatic to the bones and liver.  He takes opiate analgesics with adequate pain control.  The patient has become increasingly debilitated over the past 6 months and requires assistance with most activities of daily living.  His caregiver notes that the patient has chronic constipation with 1 or 2 hard bowel movements per week, but over the past 2 days he has been incontinent of small volume soft stools.  The patient has also been having mild nausea and decreased appetite but has had no fever, chills, vomiting, or dysuria.  There is no visible blood or mucus in the stool.  Temperature is 37 C (98.6 F) , blood pressure is 116/74 mm Hg, and pulse is 86/min.  Abdomen is distended but soft with mild diffuse tenderness and normal bowel sounds.  Which of the following is the most appropriate next step in management of this patient?

A) Advise as-needed loperamide
B) Evaluate for fecal impaction
C) Obtain CT scan of the abdomen
D) Perform stool testing for infection
E) Refer for anorectal manometry

Correct Answer:

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