PSEUDO‐OBSTRUCTION DUE TO FOREIGN BODY: IMPORTANCE OF GOOD PHYSICAL EXAMINATION

Abstract

Constipation is a significant problem in elderly nursing home residents.1 It is commonly managed using prefilled enemas, because they are easy to use and are considered to be user friendly, but we report a unique case of an elderly nursing home resident presenting with abdominal pain, refusal to eat, and diagnostic studies suggesting pseudo-obstruction. She was found to have the protective shield of the enema bottle in the sigmoid colon. A 94-year-old female nursing home resident was admitted to exclude bowel obstruction after she had been complaining of vague abdominal pain, distension, and refusal to eat and take medications. She appeared frail and poorly nourished. There was minimal abdominal distension, and bowel sounds were present in all four quadrants. She had a history of constipation and was given enemas in the nursing home with no significant bowel movements. She also had a diagnosis of moderate to severe dementia and multiple other comorbidities that are commonly seen in geriatric populations. She had difficulty describing her symptoms to the hospital staff and continued to refuse to eat while in the hospital despite encouragement from family members and staff. Abdominal films confirmed colonic ileus. A computed tomography (CT) scan of the abdomen with contrast did not show any structural obstruction, but upon digital rectal examination, there was a hard tubular object felt that did not have the texture of impacted fecal matter. A rectal examination performed by the gastroenterologist confirmed the presence of an object. The patient then underwent flexible sigmoidoscopy the following morning, and the “hard tubular object” turned out to be the protective shield of the enema bottle tip, as seen in Figure 1. Upon returning to the medical floor after the procedure, the patient indicated to her nurse that she was feeling hungry and ate a bowl of ice cream and took her medications. Left panel: Foreign body in sigmoid colon as seen during sigmoidoscopy. Right Panel: Removed foreign body (protective shield of an enema bottle). Foreign body in the rectum has been described extensively in the surgical and radiological literature.2-7 Although the case series included elderly patients, the mean age was 50. Earlier reports have described seed bezoars to be commonly detected foreign bodies in elderly people.8, 9 The prevalence and nature of foreign bodies in the institutionalized and community-dwelling geriatric population is unknown. The presence of dementia, which is common in this age group, adds to the difficulty of reaching the correct diagnosis. There have been reports of retained enema sheath in patients undergoing preparation for barium enema on an outpatient basis,10 but they were readily identified on the subsequent barium contrast study. Surprisingly, the foreign body in our patient case was not detected on contrast CT scan of the abdomen and pelvis, underscoring the importance of a good and complete physical examination. Our case report provides a unique opportunity to bring awareness to caregivers who care for elderly patients, especially those with dementia. Although not many cases like this have been reported in the literature, the scenario may not be uncommon and can lead to undesirable complications. Removal of the protective shield before administration of the enema and checking for the enema tip after administration of the enema will help avoid these complications. Ultimately, manufacturers of these prefilled enemas should consider redesigning their product to eliminate this complication altogether. Conflict of Interest: The authors have no financial disclosures to report and no conflict of interest in regards to this letter. Author Contributions: All the authors wrote, read, and approved this letter. Sponsor's Role: No sponsor involvement.