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Iatrogenic Rectal Perforations from Phosphate Enemas: A Retrospective Series over 1 Year of Activity in a University Hospital

Perforations of the rectum are important events that usually require emergency admissions and laparotomies to divert the fecal mainstream and repair the defect. Although common causes include sexual traumas or accidents, iatrogenic perforations are less common in the literature. Perforations from enemas have been reported during preparations for barium studies (incidence of 0.02 to 0.2%, approximately two cases per year)1 and involve not only the rectum, but also the sigmoid colon, caecum, transverse colon, rectosigmoid junction, and the colostomy site. In these cases, they all inevitably lead to extravasation of the contrast and fecal flow in the abdominal cavity.2 Albeit rare, their mortality rate is 17 to 66 per cent as a result of fecal and barium peritonitis.1, 2 Long-term morbidity can also be significant as a result of adhesive small bowel obstruction or retroperitoneal fibrosis with ureteral stenosis. Careful administration of the contrast with controlled pressures in cases of potential strictures (i.e., chronic Crohn’s diseases, malignancy) as well as awareness of the complication by the radiological and surgical personnel is important to reduce the incidence and the mortality. Iatrogenic perforations can also be caused by the noncareful administration of phosphate enemas for the same pathogenetic mechanisms of barium studies; however, no specific literature report exists in the literature. In the present study, we retrospectively reviewed our experience with these peculiar causes of perforation over one year of activity in our university hospital (January to December 2011). Medical notes of patients were retrieved and demographics and clinical data, including outcomes, were collected. We excluded from the analysis those patients in which the rectum was perforated by other causes (i.e., sexual traumas). Eight patients were admitted in the emergency department of the Tor Vergata University Hospital for iatrogenic perforations resulting from phosphate enemas (Table 1). All of them had an advanced age (82 ± 10 years); most were males (eight/five [63%]) and affected by neurologic diseases (six/eight [75%]). They usually presented from nursing homes and after two days from the phosphate administration (48 ± 21 hours) with a clinical picture of an acute abdomen, in one case with also associated septic shock. They all underwent a surgical operation with intraoperative findings of fecal peritonitis in all cases. This was diffuse in 75 per cent of them (six of eight) and localized in 25 per cent (two of eight). When data were available, the location of the hole was anterior in 80 per cent of cases (four of five) and anterolateral in 20 per cent (one of five). The operation of choice has been a Hartmann’s resection in most cases (85.7% [six of seven]) and a diverting loop colostomy in only one patient (14.3% [one of seven]). Postoperative complications were frequent in our series and involved two pneumonia with pleural effusions, two septic shock, and one sepsis. Mortality corresponded to 50 per cent of patients (four of eight). None of the patients who survived the perioperative period had at long-term follow-up the stoma closed and the bowel continuity restored as a result of the surgical risks involved. Rarely the colon may burst as a result of excessive transmural pressure alone. Usually, a colon weakened by age (the tensile strength of the bowel wall is impaired in elderly patients), iatrogenic trauma (injury to the rectal mucosa resulting from the enema tip or retention balloon), disease (stricture, neoplasm, inflammation, ischemia, Hirschsprung’s disease), colostomy, medications (steroids), or invasive procedures (deep biopsy or polypectomy) is more likely to perforate during an enema. According to the classification adopted by de Feiter and colleagues,1 five different types of rectal perforations can be individuated after barium enema administration: 1) perforations of the anal canal below Address correspondence and reprint requests to Gianpiero Gravante, M.D., Ph.D., Department of Colorectal Surgery, George Eliot Hospital, George Eliot Road, Nuneaton, CV10 7DJ, U.K. E-mail: ggravante@hotmail.com.