Rectal perforation in ulcerative colitis: complication of an enema tip - 23/08/11
Doi : 10.1016/j.gie.2008.08.023
| Commentary Here we have a complication not from the infusate, but rather from the enema tip or nozzle (an interesting word that is derived from the root word, nosle or nosel, meaning nose). Enema nozzles vary in size, shape, and material, but all have the capacity to cause grievous injury, as in this case. Two anatomic points of which we should be aware are these: (1) The anorectal angle is such that most perforations will involve the anterior wall of the rectum. Hence, after insertion, the axis of the nozzle should be directed slightly posteriorly to keep the tip in the center of the bowel lumen. (2) The columnar mucosa above the pectinate line is insensate and, therefore, it is unusual that patients develop pain immediately after rectal perforation unless the infusate is irritating; pain is felt hours later when fecal contamination occurs. Patients should be cautioned to remove any protective caps overlying the nozzle, lest the endoscopist be called later to remove one that has been shot deep into the colon when the enema was administered; to lubricate the tip if it is not already lubricated; and to insert it gently. Special caution should be exercised by those with proctitis, rectal diverticula, or anorectal strictures, and with masses that might angulate or otherwise compress the rectum, such as a fibroid uterus or enlarged prostate. Rectal perforation doesn’t carry the same risk of peritonitis as does perforation above the peritoneal reflection, but it too is not pleasant and may be associated with pararectal abscess and pelvic sepsis. I am reminded of the Lao Tzu quotation, “anticipate the difficult by managing the easy.” Lawrence J. Brandt, MD Associate Editor for Focal Points |
© 2009
American Society for Gastrointestinal Endoscopy. Pubblicato da Elsevier Masson SAS. Tutti i diritti riservati.
Vol 69 - N° 2
P. 344 - febbraio 2009 Ritorno al numero
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