Author: Dr Tony Duffy, Consultant Palliative Medicine, Edinburgh, Scotland
Introduction:
In the context of the current UK assisted dying debate, the terms ‘faecal’ and ‘faeculent’ vomiting have been publicly employed, including during the Second Reading debate in parliament. This terminology has featured in stories of unpleasant deaths to contextualise why some people feel assisted suicide should be enshrined in law. However, what do these terms mean, and is there a difference between them?
Background:
In the world of clinical medicine and in our work in practice, the act of vomiting one’s own faeces (‘faecal vomiting’) is actually exceedingly rare; a review of the medical literature provides a dearth of information with almost no comment on it. More frequently, the term ‘faeculent vomiting’ is used by healthcare staff, sometimes loosely, to describe vomits that are unpleasant smelling and brown in colour, but it is vanishingly rare that the vomit includes actual faeces.
Definitions:
To understand these issues we first have to define what faeces or faecal matter actually is: content that has passed through the sterile tracts of the stomach and then the small intestine (about 18 foot long in average person, also sterile which means there are no faecal bowel flora/bacteria normally), to the end of the small intestine where there is a valve (called the ileo-caecal valve) that is a one-way system into the shorter large bowel (about 5 foot long). The large bowel is where faeces are formed due to the removal of water (solidifying stool) and the actions of over 400 bacterial species ( e.g.enterococcus faecalis) which work on the waste products that the small bowel has not absorbed. Faeces reaching the rectum will be comprised of almost 50% bacterial biomass with undigested food, intestinal mucus, intestinal cells and water completing the contents.
Bowel obstruction:
A bowel obstruction is a blockage in the bowel that either partially or completely stops matter from passing from one part of the bowel to the next. Bowel obstruction can occur in people with bowel or ovarian cancers (who may be in their last six months of life, but may also be at the start of their diagnosis), or can be the result of abdominal adhesions from previous surgery (in which case the patient may have many years to live).
Both complete and partial bowel obstructions may resolve with conservative management, which includes giving the bowel a rest from eating and drinking, and offering anti-sickness medications. Most patients with bowel obstruction (about 75%) have a small bowel obstruction, (1) meaning that the blockage is the part of bowel where faeces has not formed yet. CT imaging in small bowel obstruction may reveal faecal-like matter (small bowel faeces sign) which is thought to comprise of partially digested food which has become dehydrated, small bowel mucosal cells and local bacterial overgrowth. While a small bowel obstruction can result in abdominal pain and variations of darker malodorous vomiting , the matter vomited would not be faeces originating from the large bowel. This is most likely what the term “faeculant vomiting” is referring to.
Even in the rarer large bowel obstruction, it would be very difficult for faeces to make its way back from the large bowel, past the one-way ileo-caecal valve into the small bowel, and then track upstream all the way (18 foot) to the stomach. It may happen if there is a tremendous backlog or build up, the ileo-caecal valve is incompetent and if the muscular contractions of the bowel wall work in a way that propels bowel content in the wrong direction, but this would be exceedingly rare and unusual.
Fistulae:
What can – very rarely – occur is an abnormal connection, or fistula, between the large bowel and small bowel or stomach. In this case, faecal matter could move from the large bowel to the stomach requiring surgical intervention to redivert faecal flow. Other surgical procedures that can be helpful when people have bowel obstructions are an ileostomy or a colostomy, which would provide a route for bowel contents to leave the body if the normal route is blocked, in essence a by-pass. Surgical procedures such as these are not uncommonly done, even when patients have a relatively short prognosis, as a way of palliating symptoms and providing relief.
Management options:
Most surgical, medical, oncology and palliative care departments will have bowel obstruction management protocols. These will include more conservative approaches such as reducing gut odema with steroids, giving anti-sickness medicines via a syringe driver (because absorption of medicines taken orally is likely to be poor), giving the gastro-intestinal tract a rest while providing intravenous fluids and/or nutrition, and inserting thin tubes from the nose to the stomach to help with drainage of any excess stomach contents. Some of our patients leave hospital to go back home even with complete bowel obstruction, and they eat and drink several times a day, and then drain their nasogastric tube an hour or two after their meals. Some of the ingested food will have been absorbed, the rest is shed via the tube into a bag. The volume of vomitus can also be reduced using anti-secretory medications such as octreotide and hyoscine butylbromide.
Discussion:
Frustratingly, the terms ‘faecal’ or ‘faeculent’ vomiting can be used loosely in health and care settings, often just because the vomit is made up of old undigested food and is dark in colour or malodorous. While not pleasant, in the vast majority of cases this does not represent faecal matter. Surgical colleagues point out that the terms faecal and faeculent are overused by staff in hospitals when describing vomit, and that even vomits from infections such as Norovirus have been falsely described as faeculent or faecal. Patients and/or their relatives may of course pick up on the language used by staff, and unsurprisingly, this is not a description many will forget.
Conclusion:
This raises issues of responsible professional use of medical language and how it is picked up by members of the public, especially if mentioned flippantly and without much explanation. Another issue is that the very patients who may be suffering the consequences of bowel obstruction may be the least likely ones to be able to go through with an assisted death, in the way that a future UK Assisted Dying bill is being envisaged: the oral route, where vast amounts of different medications have to be ingested, at different time points, would not work, because the toxic cocktail would be vomited up, or too slowly/not at all absorbed. And even giving it intravenously would be a significant challenge, with a patient very unlikely feeling well enough or able to comply with the instructions of intravenous self-administration when they are in extremis, and in reality need expert help with symptom control and reversing any reversibles.
References:
(1) Markogiannakis H, Messaris E, Dardamanis D, Pararas N, Tzertzemelis D, Giannopoulos P, Larentzakis A, Lagoudianakis E, Manouras A, Bramis I Acute mechanical bowel obstruction: Clinical presentation, etiology, management and outcome. World J Gastroenterol 2007; 13 (3): 432-437
More from Tony Duffy:
https://www.palliative-reflections.com/