Death by Enema: A Rare Case of Rectal Necrosis Following Homemade Enema Administration

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Introduction: Enemas have been a mainstay of constipation management and used safely for bowel cleansing since the 17th century. Homemade enema preparations are becoming more popular both for bowel cleansing and for administration of coffee and other drugs. Generally safe and well-tolerated, enemas have been associated with complications including electrolyte disturbances, bowel perforation, and rectal bleeding. The following is a rare case of rectal necrosis following homemade enema administration that resulted in death. Case Report: A 52-year-old Caucasian male with history of alcoholic cirrhosis, esophageal varices, and peptic ulcer disease presented with a 3-day history of bright red blood per rectum and rectal pain after self-administering homemade rectal enemas. On admission, he was alert and oriented with normal abdominal exam and blood pressure, but was noted to have mild tachycardia and tachypnea. Frank hematochezia was witnessed and rectal exam showed tender hemorrhoids and anal fissure. Lab work was notable for hemoglobin of 5.1 g/dL, INR of 2.2, and platelet count of 25 x109/L. Packed red blood cells, fresh frozen plasma, and platelets were transfused prior to an urgent esophago-gastro-duodenoscopy (EGD) which showed no evidence of active upper GI bleeding. The patient then developed an ileus after administration of bowel preparation for a planned colonoscopy. He also had alcohol withdrawal requiring intubation for severe agitation refractory to benzodiazepines. He later developed septic shock with a fever of 104 degrees F. Norepinephrine, empiric IV vancomycin, and piperacillin-tazobactam were given, and abdominal CT scan revealed large bowel obstruction extending to the anus. Rectal exam prior to colonoscopy for decompression was significant for an ecchymotic and edematous appearing perineum. The colonoscopy itself was significant for contiguous necrotic-appearing tissue extending from the rectum up to 25 cm from the anal verge, where a clear demarcation with normal mucosa was seen. Surgical consultation deemed the patient a poor candidate for operation, given his underlying cirrhosis and high MELD score. His code status was transitioned to comfort measures and he passed away shortly afterwards. Discussion: Rectal necrosis following enema administration is a rare and morbid complication that has only been reported a few times in the past. Although uncommon, its potential deserves greater public awareness, given the increasing popularity of colonic cleansing and homemade coffee enema administration. Patients who engage in the use of homemade enemas should be educated about their potentially negative consequences.