‘Flatus tube enema’ as an alternative to flexible sigmoidoscopy in reducing colonic volvulus and pseudo-obstruction: letter

Abstract

Dear Editor: Pseudo obstruction and colonic volvulus are common in elderly patients. Sometimes, it may be difficult to distinguish one from the other. Insertion of a blind flatus tube is an easy, readily available, low-cost, first-line treatment for both of them. Flexible sigmoidoscopy may be required in difficult cases particularly when the flatus tube fails. Rectal tube enemas have been known to clean the left colon for more than two decades. However, the use of this technique for treating the colonic pseudo-obstruction and volvulus has not been described before. Here, we describe a technique which we call ‘flatus tube enema’ and it is useful in dealing with an acute abdomen associated with colonic volvulus and pseudo-obstruction. In the first case, a 78-year-old gentleman was admitted to the hospital with 1-week history of abdominal discomfort and constipation. He suffered from Parkinsonism and had a limited mobility. Clinical examination showed a gaseously distended upper abdomen and obstructive type of bowel sounds. An abdominal X-ray demonstrated volvulus possibly involving the transverse colon. A well-lubricated flatus tube (150 cm long) was inserted per rectum blindly directed by the index finger. Initially, the tube kept reflecting back at the rectosigmoid junction. Eventually, it went through and resulted in the release of a large amount of gas. Subsequently, a double phosphate enema was administered through the rectal flatus tube. His condition totally resolved. He was not investigated further because of his poor general health. He was discharged home without needing a flexible sigmoidoscopy. In the second case, a 92-year-old lady was admitted from a residential home with painless abdominal distension of 4 days’ duration. She had been admitted twice in the past with a similar problem, which had settled with enemas and insertion of flatus tubes. Four weeks prior to her admission, she sustained a fracture of neck of femur, which was treated with a dynamic hip screw. She was taking buprenorphine patch for spinal canal stenosis. On examination, she appeared comfortable and the vital observations were within normal limits. Examination of the abdomen showed moderate distension, tympanic on percussion, and tinkling bowel sounds. Digital rectal examination showed an empty rectum. An abdominal X-ray showed very grossly dilated transverse colon measuring 15 cm in size. The differential diagnosis in her case was a transverse colonic volvulus or pseudo-intestinal obstruction. The patient was seen at midnight and it was practically difficult to organize a flexible sigmoidoscopy. Therefore, a blind flatus tube was inserted. However, it was not successful and it may have been because of the tube bending upon itself. Two phosphate enemas were administered through the flatus tube and leaving it in situ. The patient opened her bowels and passed wind. A flexible sigmoidoscopy was performed in the morning and some residual twisting of the sigmoid was present and it was completely deflated. Colonic volvulus and pseudo-obstruction are usually associated with a loaded colon. A single phosphate enema given per rectum may not reach the proximal end of the left colon. Our technique of high phosphate enema via a flatus tube resolved a transverse/sigmoid colon volvulus in case 1 and partly reduced the colonic dilatation in case 2. It may Int J Colorectal Dis (2009) 24:725–726 DOI 10.1007/s00384-009-0644-z