SEPTIC SHOCK IN AN ELDERLY PATIENT ON DIALYSIS: ENEMA‐INDUCED RECTAL INJURY CONFUSING THE CLINICAL PICTURE

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To the Editor: Although enema administration is considered a benign procedure, it is not totally devoid of risk for the patient. Severe anorectal injuries, although uncommon, have been reported.1-5 In the case that follows, rectal perforation from an enema is described to highlight this dramatic complication from a common medical procedure. A 73-year-old male, resident of a skilled nursing facility, was admitted for fever, vomiting, and hypotension. The patient's medical history was significant for end-stage renal disease requiring dialysis, congestive heart failure, and vertebral fractures treated with narcotics for pain control. The day before the admission, a sodium phosphate enema was given for constipation. Mild rectal bleeding complicated the procedure. Twenty-four hours after the enema, the patient experienced fever, chills, and vomiting. He was transferred to the emergency department and on arrival was found to be in septic shock. Suspecting a complication from the recent enema, a computed tomography scan of the pelvis was performed, revealing perirectal air (Figure 1). The patient was treated with intravenous fluids, vasopressors, and antibiotics (piperacillin/tazobactam, vancomycin, and tobramycin) and experienced rapid improvement in his clinical condition. Surgical intervention was deferred, and a repeat computed tomography scan revealed resorption of perirectal free air. The patient recovered to baseline. Computed tomography scan of the pelvis revealing free air in the perirectal area (arrow). Constipation is a prevalent problem in the elderly population,6 and enemas are frequently prescribed as a remedy. Rectal injury from enemas is an underappreciated event worth highlighting. The mechanism of injury from enema administration may be mechanical, chemical, or both. Clinical clues to the development of this complication include pain and bleeding. The rectum is insensitive to pain, and if significant discomfort follows an enema, then leakage of colonic contents or the enema solution itself into the perirectal space should be considered. Bleeding after enema administration is also a common premonitory sign when the rectum is perforated; therefore, rectal pain and bleeding are important indicators of possible rectal injury and should prompt further evaluation. When this patient initially presented to the hospital, thought was first given to dialysis access sepsis, which is common in dialysis patients, but awareness of the recent enema and of perforation as a complication of enema administration altered the therapeutic and diagnostic approach. In the elderly, a careful history of recent treatments is important. In the appropriate clinical context, if an enema has been recently given, the clinician should be aware of the potential complications of the procedure. Warning signs such as abdominal pain, rectal bleeding, and fever after an enema should arouse suspicion. Failure to appreciate the symptoms and signs of rectal injury can result in delay in the initiation of proper medical and surgical therapy.