AN UNUSUAL CAUSE OF RECURRENT MASSIVE GASTROINTESTINAL BLEEDING IN THE MICU

Abstract

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Fecal incontinence is a commonly encountered condition occurring in up to 33% of critically ill patients. The etiology of diarrhea or fecal incontinence is usually multifactorial and can lead to skin breakdown, ulceration, and infection. Managing diarrhea in the intensive care unit(ICU) patients can be a challenging problem. Flexi-Seal Fecal Management system(FSMS) is commonly used in ICU settings, and provide a safe and effective diversion of stool away from the skin. CASE PRESENTATION: 32-year-old Hispanic female, with a past medical history of insulin-dependent diabetes mellitus, who initially presented with shortness of breath found to have influenzas B, also had diabetic ketoacidosis (DKA). She was admitted initially to the medical ICU for DKA management, her ICU course was complicated by hypoxic respiratory failure requiring mechanical ventilation, septic shock, and developed bilateral basilic and cephalic vein thrombosis, for which she was started on heparin infusion. Because of the prolonged stay and acute diarrhea, a FSMS was placed and remained in place for 16 days. She developed acute blood loss anemia and significant hematochezia. Flexible sigmoidoscopy showed rectal bleeding ulcer secondary to prolonged rectal tube placement, the bleeding was controlled with two clips, but she continued to have recurrent bleeding with hemodynamic instability, requiring multiple blood transfusions. The patient underwent colonoscopy, no other source of bleeding was identified except the rectal ulcer, so another clipping was placed, however, the patient continued to have recurrent bleeding per rectum, a second flexible sigmoidoscopy was performed, which didn’t show active bleeding and three clips were still in place. Eventually, the bleeding stopped without any further intervention. She required a total of three units of packed RBCs. DISCUSSION: The use of fecal management systems in ICU has been more commonly utilized, because of their effectiveness in diverting fecal material away from the patient. The Flexi-Seal fecal management system is the most widely used device designed which can be used up to 30 days. It involves a balloon inflated with saline to secure the tube in place. Although Flexi-Sealdevice is considered safe overall. However, it is important to caution with prolonged use of this device. There have been few reported cases in literature for lower gastrointestinal bleeding secondary to the fecal management system, either in the setting of anticoagulation use or without it. The ulcer is usually caused by direct pressure of the balloon on rectal mucosa, and semisolid fecal build up above the balloon. Patients on anticoagulation should be closely monitored for any signs of lower gastrointestinal hemorrhage. CONCLUSIONS: FSMS is overall a safe system, but the continued need for the utilization of FSMS should be assessed daily with a low threshold for removal once the indication resolved. Reference #1: Tiwari A, Sharma H, Qamar K, Alastal Y, Sodeman T, Nawras A. The Traumatic Tube: Bleeding Rectal Ulcer Caused by Flexi-Seal Device. Case reports in gastrointestinal medicine. 2017;2017. Reference #2: Beitz JM. Fecal incontinence in acutely and critically ill patients: options in management. Ostomy Wound Manage. 2006 Dec 1;52(12):56-66. DISCLOSURES: No relevant relationships by Rami Ahmad, source=Web Response