Medical and surgical treatment in patients with intellectual disabilities (IDs) presents a challenge to physicians and surgeons alike, as informed consent and longitudinal treatment are difficult to achieve. Severe constipation has a high prevalence in persons with IDs and is found in this population at a rate almost double that experienced by the general population. This case report highlights a middle-aged male with severe IDs, who presented with abdominal distention and behavior consistent with abdominal pain from constipation. The patient was found to have severe, chronic constipation, with an associated large, calcified fecalith in the rectum and an impressively expanded sigmoid and descending colon, secondary to a massive, chronic fecaloma. Resolution of the cause of constipation could not be achieved due to a combination of social factors, thereby highlighting the importance of advocating for and developing long-term treatment plans for prevention in such patients.