Bowel perforation due to retained enema nozzle in a patient of anorectal malformation

Sir,

Bowel management using colonic washouts is frequently practiced in children with fecal incontinence. Pena et al have described algorithms for management of such children and have reported success rates of more than 95%.[1,2] We too have successfully initiated the bowel management program in many of our patients. Although it is generally a safe procedure, we encountered a case of a sigmoid perforation due to bowel washes in a child with anorectal malformation. Although this complication has been seen in peripheral hospitals due to enema nozzles and rectal thermometers, retention of enema nozzle has not been reported in the setting of bowel management in the available literature.

A 5-year-old boy who had completed 3-stage management of high anorectal malformation was started on bowel washes for management of fecal incontinence. A plastic enema can that is routinely available was used. The can has a detachable plastic tubing and two different sizes of plastic nozzles which can be attached to the plastic tubing (Figure 1- inset). About 2 months after initiation of washes the child presented to the emergency room with abdominal distension, feculent vomiting, and constipation. Clinical examination showed features of peritonitis. Erect X-ray abdomen showed gas under diaphragm. The child was resuscitated and taken up for exploratory laparotomy.

Figure 1.

Sigmoid perforation due to enema nozzle (Inset - Enema can with plastic tubing and 2 nozzles)

On exploration, there was a perforation in the sigmoid colon about 5 cm from the peritoneal reflection [Figure 1]. The enema nozzle was seen to be jutting out of the perforation. Primary closure of the perforation was performed after removing the foreign body. Post-operative recovery was uneventful and the child was sent home on the 7^th post-operative day.

Bowel wash for management of pediatric fecal incontinence can be mastered easily by parents under the guidance of a doctor or a trained nurse. Complications such as hypernatremia due to excessive use of salt in enema fluid and colitis due to use of phosphate enemas have been mentioned by Bischoff et al in their experience.[1] However, mechanical complication due to accidental retention of the enema nozzle has not been reported.

In order to prevent this complication, a long red rubber catheter or a Foley's catheter may be used to administer the enema. This is also recommended by Bischoff et al.[3] These have the added advantage of preventing leakage of the enema fluid. Accidental breakage and retention may still be a possibility.

Bowel management has changed the lives of many children with fecal incontinence. Although it is a safe and easy procedure, detailed instructions to the parents and spending time to explain the procedure may be beneficial to avoid such problems in the future. Careful vigilance on the part of the caregiver also needs to be highlighted to avoid such a complication.