Can unrecognized fecal loading without infrequent bowel movements be a cause of symptoms in a subset of patients with functional bowel disorders?

Infrequent bowel movements are a common feature of constipation, but fecal loading as a cause of symptoms in patients with regular bowel movements has not previously been evaluated. The aim of this preliminary study was to assess prospectively if fecal loading may be a cause of bowel symptoms in patients with regular bowel movements. Consecutive patients attending a gastroenterology clinic for functional bowel symptoms (FBD) not including infrequent bowel movements and who did not fulfil the criteria for constipation-predominant irritable bowel syndrome or functional constipation underwent plain abdominal radiography. Those with fecal loading received dietary advice and laxative treatment. The reproducibility of determination of fecal loading using the Leech score was assessed 'blindly' by a consultant radiologist. Twenty-six of 74 patients with FBD but not infrequent bowel movements had fecal loading demonstrated on abdominal radiology. Their Leech scores were significantly higher than those of control patients matched for age, sex and hospital (median 6 vs. 4, IQR 5-7 vs. 3.5-5, p < 0.001). Three out of 20 patients (15%) who returned for review after dietary advice and laxatives were asymptomatic and 17/20 (85%) had improved. Fecal loading may therefore cause bowel symptoms in patients who move their bowels regularly and dietary and laxative treatment may then improve these symptoms. This approach may prove cost-effective as an empirical interim measure especially where healthcare resources are limited and where sophisticated imaging is not readily available.