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The tip of the iceberg of colorectal perforation from enema: a systematic review and meta-analysis

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Abstract

Background

Although rare, perforation following an enema used to treat constipation is a dangerous complication. However, no recommendations or guidelines for enema use are available. So, in common clinical practice, the diagnostic approach and the treatment are not standardized. In an attempt to resolve this clinical dilemma associated with high mortality and potential medicolegal claims for malpractice, we have performed a systematic review and meta-analysis of studies reporting on colorectal perforation secondary to enema use for adult patients with constipation.

Methods

A systematic search of PubMed, Web of Science and Scopus was performed according to the PRISMA statement up until February 2020. Studies that reported on colorectal perforation from enema use in adult patients with constipation were included. The primary outcomes were the rate of hospital mortality and pooled prevalence estimates of mortality from perforation secondary to enema use. The secondary outcomes were the administration of rectal enemas, site of visceral perforation, signs, symptoms, radiological evaluation, and type of treatment

Results

A total of 15 studies were included in the final analysis (49 patients). Across all studies, the pooled prevalence estimate of mortality for patients with perforation secondary to enema use was 38.5%, (95% CI [22.7%, 55.5%]). This rate was lower in patients who had surgery (35%) than in patients treated conservatively (57.1%). The sites of perforation were intraoperatively reported in 84% of cases, but in 16% of patients the rectal perforation was undiagnosed, and surgical decision making was problematic. The primary location of the perforation was the rectum in 80.9% of the patients. The enema was administered by a nurse in 90% of the cases, self-administered in 7.5% and a family doctor in 2.5%. The main objective of emergency surgery in this setting is resection of the perforation caused by the enema; when it is not possible to resect the perforated rectum, faecal diversion is needed. Hartmann’s procedure was most commonly performed by the surgeons in this review (60.7%), with other reported treatments included a diverting proximal loop colostomy and sigmoid segment exteriorization

Conclusions

Considering the studies available, it is not possible to undertake a thorough evaluation of enema use, including the associated complications and their management. Further data are required to allow the development of guidelines to advice on safe enema use and management of complications.

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References

  1. Akhavan R, Chavoshi K, Bolvardi E, Foroughian M, Abbasi B (2019) Iatrogenic rectal perforation following self-administered water enema. Acta Sci Med Sci 3(7):43

    Google Scholar 

  2. Higgins PD, Johanson JF (2004) Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol 99(4):750–759

    Article  PubMed  Google Scholar 

  3. Choung RS, Locke GR 3rd, Schleck CD, Zinsmeister AR, Talley NJ (2007) Cumulative incidence of chronic constipation: a population-based study 1988–2003. Aliment Pharmacol Ther 26(11–12):1521–1528

    Article  CAS  PubMed  Google Scholar 

  4. Vazquez Roque M, Bouras EP (2015) Epidemiology and management of chronic constipation in elderly patients. Clin Interv Aging 10:919–930

    PubMed  PubMed Central  Google Scholar 

  5. Obokhare I (2012) Fecal impaction: a cause for concern? Clin Colon Rectal Surg 25(1):53–58

    Article  PubMed  PubMed Central  Google Scholar 

  6. Robertson-Malt S, Hodgkinson B, Joanna Briggs Institute (2008) Management of constipation in older adults. Aust Nurs J. 16(5):32–35

    PubMed  Google Scholar 

  7. Hussain ZH, Whitehead DA, Lacy BE (2014) Fecal impaction. Curr Gastroenterol Rep 16(9):404

    Article  PubMed  Google Scholar 

  8. Portalatin M, Winstead N (2012) Medical management of constipation. Clin Colon Rectal Surg 25(1):12–19

    Article  PubMed  PubMed Central  Google Scholar 

  9. Serrano Falcón B, Barceló López M, Mateos Muñoz B, Álvarez Sánchez A, Rey E (2016) Fecal impaction: a systematic review of its medical complications. BMC Geriatr 16:4

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  10. Hinton JM, Lennard-Jones JE (1968) Constipation: definition and classification. Postgrad Med J 44(515):720–723

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097

    Article  PubMed  PubMed Central  Google Scholar 

  12. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg 73:712–716

    Article  PubMed  Google Scholar 

  13. Schwarzer G, Chemaitelly H, Abu-Raddad LJ, Rücker G (2019) Seriously misleading results using inverse of Freeman-Tukey double arcsine transformation in meta-analysis of single proportions. Res Synth Methods 10(3):476–483

    Article  PubMed  PubMed Central  Google Scholar 

  14. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (eds) (2019) Cochrane handbook for systematic reviews of interventions, 2nd edn. Wiley, Chichester

    Google Scholar 

  15. Rani A, Gupta P (2014) A case of perforation of rectum due to self-administered enema in a pregnant woman. Int J Reprod Contracept Obstet Gynecol 3:783–784

    Article  Google Scholar 

  16. Venditti D, Gravante G, Sena G, Orsaria P, Petrella G (2013) Iatrogenic rectal perforations from phosphate enemas: a retrospective series over 1 year of activity in a university hospital. Am Surg 79(5):E187–E189

    Article  PubMed  Google Scholar 

  17. Choi PW (2013) Colorectal perforation by self-induced hydrostatic pressure: a report of two cases. J Emerg Med 440(2):344–348

    Article  Google Scholar 

  18. Mori H, Kobara H, Fujihara S, Nishiyama N, Kobayashi M, Masaki T, Izuishi K, Suzuki Y (2012) Rectal perforations and fistulae secondary to a glycerin enema: closure by over-the-scope-clip. World J Gastroenterol 18(24):3177–3180

    Article  PubMed  PubMed Central  Google Scholar 

  19. Kalkan IH, Oztaş E, Yildiz H, Beyazit Y, Suvak B, Boyabatli M (2012) Rectal perforation as a result of self-administration of retrograde enema in an elderly dementia patient. Geriatr Gerontol Int 12(3):564–565

    Article  PubMed  Google Scholar 

  20. Fu WP, Quah HM, Eu KW (2009) Traumatic rectal perforation presenting as necrotising fasciitis of the lower limb. Singap Med J 50(8):e270–e273

    CAS  Google Scholar 

  21. Leal V, Tavares C, Almeida K, Rego L, Soares M (2006) Perfuração Intestinal por Enema Aquoso—Uma complicação Pouco Conhecida. Rev Bras Coloproct 26(3):325–327

    Article  Google Scholar 

  22. Coli P (2005) Subcutaneous emphysema of the thorax and rectal perforation. Chirurgia 18(5):349–352

    Google Scholar 

  23. Nakamura H, Iyoda M, Sato K, Kitazawa K (2005) Retrograde hydrostatic irrigation enema-induced perforation of the sigmoid colon in a chronic renal failure patient before colonoscopy. J Int Med Res 33(6):707–710

    Article  CAS  PubMed  Google Scholar 

  24. Bobba RK, Arsura EL (2004) Septic shock in an elderly patient on dialysis: enema-induced rectal injury confusing the clinical picture. J Am Geriatr Soc 52(12):2144

    Article  PubMed  Google Scholar 

  25. Topcu T (2003) Colorectal perforation due to self administered retrograde enema. Ulus Travma Acil Cerrahi Derg 9(4):297–299

    PubMed  Google Scholar 

  26. Gayer G, Zissin R, Apter S, Oscadchy A, Hertz M (2002) Perforations of the rectosigmoid colon induced by cleansing enema: CT findings in 14 patients. Abdom Imaging 27(4):453–457

    Article  CAS  PubMed  Google Scholar 

  27. Paran H, Butnaru G, Neufeld D, Magen A, Freund U (1999) Enema-induced perforation of the rectum in chronically constipated patients. Dis Colon Rectum 42(12):1609–1612

    Article  CAS  PubMed  Google Scholar 

  28. Madhala O, Greif F, Cohen M, Lelcuk S (1998) Major rectal perforations caused by enema: is surgery mandatory? Dig Surg 15(3):270–272

    Article  CAS  PubMed  Google Scholar 

  29. De Giorgio R, Ruggeri E, Stanghellini V, Eusebi LH, Bazzoli F, Chiarioni G (2015) Chronic constipation in the elderly: a primer for the gastroenterologist. BMC Gastroenterol 15:130

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  30. Niv G, Grinberg T, Dickman R, Wasserberg N, Niv Y (2013) Perforation and mortality after cleansing enema for acute constipation are not rare but are preventable. Int J Gen Med 6:323–328

    Article  PubMed  PubMed Central  Google Scholar 

  31. Peate I (2015) How to administer an enema. Nurs Stand 30(14):34–36

    Article  PubMed  Google Scholar 

  32. Kume K, Watanabe T, Oshima J, Yoshikawa I, Harada M (2014) Rectal perforation caused by mesalazine enema in a patient with ulcerative colitis. Endoscopy. 46(Suppl 1):E190

    PubMed  Google Scholar 

  33. Tanswell IJ, Irfan K, Kossakowski T, Townson G (2009) Rectal perforation in ulcerative colitis: complication of an enema tip. Gastrointest Endosc 69(2):344

    Article  PubMed  Google Scholar 

  34. Bennouna M, Anaya S, Sánchez-de-la-Nieta MD, Rivera F (2008) Enema in a patient with renal failure: a cause of severe hyperphosphatemia. Nefrologia 28(6):657–659

    CAS  PubMed  Google Scholar 

  35. Rentea RM, Fehring CH (2017) Rectal colonic mural hematoma following enema for constipation while on therapeutic anticoagulation. J Surg Case Rep. 2017(1):rjx001

    Article  PubMed  PubMed Central  Google Scholar 

  36. Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G et al (2012) Consensus statement AIGO/SICCR: diagnosis and treatment of chronic constipation and obstructed defecation (part I: diagnosis). World J Gastroenterol. 18(14):1555–1564

    Article  PubMed  PubMed Central  Google Scholar 

  37. Bove A, Pucciani F, Bellini M, Battaglia E, Bocchini R, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V et al (2012) Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol 18(36):4994–5013

    Article  PubMed  PubMed Central  Google Scholar 

  38. Bowers B (2006) Evaluating the evidence for administering phosphate enemas. Br J Nurs 15(7):378–381

    Article  PubMed  Google Scholar 

  39. Lee JM, Jung KW (2016) Self-administered enema related rectal perforation. Korean J Gastroenterol 67(3):158–160

    Article  PubMed  Google Scholar 

  40. Gomes RM, Perumal S, Kumar S, Senthilnathan P, Parthasarathi R, Rajapandian S, Palanivelu C, Raj PP (2015) Anorectal injury following faulty administration of enemas. Int J Colorectal Dis. 30(6):859–860

    Article  PubMed  Google Scholar 

  41. Turkcuer I, Serinken M, Karcioglu O, Aydin C, Kiroglu Y (2009) Perforation of the colon by high-pressure water inserted via the anal canal. S Afr Med J 99(6):437

    PubMed  Google Scholar 

  42. Davies C (2004) The use of phosphate enemas in the treatment of constipation. Nurs Times 100(18):32–35

    PubMed  Google Scholar 

  43. Armstrong M, Moore RA. Anatomy, Patient Positioning. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513320/. Updated 16 Feb 2019

  44. Di Saverio S, Tugnoli G, Orlandi PE, Casali M, Catena F, Biscardi A, Pillay O, Baldoni F et al (2009) A 73-year-old man with long-term immobility presenting with abdominal pain. PLoS Med 6(7):e1000092

    Article  PubMed  PubMed Central  Google Scholar 

  45. Anjali R, Puneet G (2014) A case of perforation of rectum due to self-administered enema in a pregnant woman. Int J Reprod Contracept Obstet Gynecol 3(3):783–784

    Google Scholar 

  46. Duarte JOM, Pereira PMLP, Sobral ASG, de Oliveira JPR, Rita HJB, de Sousa E Costa JA (2019) Rectal perforation after barium enema: a case report. Clin Case Rep 7(12):2565–2567

    Article  PubMed  PubMed Central  Google Scholar 

  47. Wilkinson J. Understanding a bowel perforation symptoms, causes, and treatments for a hole in the colon. DIGESTIVE HEALTH Medically reviewed by Priyanka Chugh, MD on January 10, 2020. https://www.verywellhealth.com/whats-a-bowel-perforation-797590. Accessed 3 Mar 2020

  48. Ciesla DJ (2016) Colon and rectal injuries. In: Asensio JA (ed) Current therapy of trauma and surgical critical care. Elsevier, New York, pp 391–394

    Google Scholar 

  49. Husabø G, Nilsen RM, Flaatten H, Solligård E, Frich JC, Bondevik GT, Braut GS, Walshe K, Harthug S, Hovlid E (2020) Early diagnosis of sepsis in emergency departments, time to treatment, and association with mortality: an observational study. PLoS ONE 15(1):e0227652

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  50. Steele SR, Johonson EK (2017) Colon and rectal trauma. In: Fazio V, Church J, Delaney C, Kiran R (eds) Current therapy in colon and rectal surgery. Elsevier, New York, pp 334–340

    Google Scholar 

  51. Ruscelli P, Renzi C, Polistena A, Sanguinetti A, Avenia N, Popivanov G, Cirocchi R, Lancia M, Gioia S, Tabola R (2018) Clinical signs of retroperitoneal abscess from colonic perforation: two case reports and literature review. Medicine (Baltimore) 97(45):e13176

    Article  Google Scholar 

  52. Kernagis LY, Levine MS, Jacobs JE (2003) Pneumatosis intestinalis in patients with ischemia: correlation of CT findings with viability of the bowel. AJR Am J Roentgenol 180(3):733–736

    Article  PubMed  Google Scholar 

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Funding

The authors have not received any personal financial benefit or other gain from the conduct of this study (information that explains whether and by whom the research was supported).

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Authors and Affiliations

  1. Department of Surgical Science, School of Medicine, University of Perugia, Perugia, Italy

    R. Cirocchi & M. Lancia

  2. Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, USA

    J. Randolph

  3. Legal Medicine and Insurance Office, Santa Maria della Misericordia Hospital, Perugia, Italy

    L. Panata & A. M. Verdelli

  4. Department of Surgical Science, Surgical Proctology Unit, Sapienza University of Rome, Rome, Italy

    D. Mascagni

  5. Department of Surgery “P. Valdoni”, Sapienza Università di Roma, Rome, Italy

    A. Mingoli

  6. Department of General Surgery, San Pietro Polyclinic, Ponte San Pietro, Italy

    M. Zago

  7. Emergency Surgery Unit, University of Pisa, Pisa, Italy

    M. Chiarugi

  8. Institute of Legal Medicine, University of Camerino, Camerino, Italy

    P. Fedeli

  9. Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK

    J. Davies

  10. Surgical Department, Emergency Surgery Unit, Sant’Anna University Hospital, Ferrara, Italy

    S. Occhionorelli

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  1. R. Cirocchi
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Contributions

RC substantial contributions to the analysis and interpretation of data; Drafting the work and revising it critically for important intellectual content; Final approval of the version to be published; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JR substantial contributions to the conception, design of the work, the analysis and interpretation of data; collated and managed the collected data; conducted the exploratory data analysis, performed and reported the statistical analysis; wrote the statistical code; drafting the work and revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. LP, AMV, DM, AM, and MC substantial contributions to the conception, design of the work; revising the work critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MZ substantial contributions to the conception, design of the work; revising the work critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. ML substantial contributions to the conception, design of the work, the analysis and interpretation of data; revising the work critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. PF substantial contributions to the conception, design of the work, the analysis and interpretation of data; revising the work critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JD substantial contributions to the conception, design of the work, the analysis and interpretation of data; revising the work critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. SO substantial contributions to the conception, design of the work, the analysis and interpretation of data; revising the work critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Correspondence to L. Panata.

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Cirocchi, R., Randolph, J., Panata, L. et al. The tip of the iceberg of colorectal perforation from enema: a systematic review and meta-analysis. Tech Coloproctol 24, 1109–1119 (2020). https://doi.org/10.1007/s10151-020-02294-7

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