Conservative treatment Barium extravasation of rectum- a case report 湯堯舜 黃宏昌 魏柏立 郭立人

Patient profile 沈XX 04114291 Sex: female Age: 55-year-old Admission on 06/30/2016 Source of patient: ER Nativity : Taiwan Occupation : 會計 Marital status : divorce Body weight 70Kg Body height 160cm BMI: 27.34 kg / m2

Chief complaint Abdominal pain with fever after barium enema study

Present illness Type II DM / Hypertension s/p laparoscopic cholecystectomy in CGMH Watery diarrhea alt with constipation in recent half year Abdominal cramping before defecation, relieved after defecation 6/14 colonoscopy: incomplete-- Colonic spasm, acute angulation –no invasive procedure performed Arrange barium enema on 6/30

Barium enema 08:30 am The examination was stopped because the patient complained persisnent lower abdominal discomfort during barium enema

ER 20:00 6/30 Vital sign: 37.3 degree, 82bpm, 16/min 149/85mmHg 100%, GCS: E4V5M6 PE: abdominal soft No muscle guarding

6/30

Impression 1.Iatrogenic retroperitoneal rectal perforation 2.Diabetes mellitus Type II 3.Hypertension

Treatment NPO, hydration Flumarin 1000mg q8h PPN with Aminofluid 1000ml/day

One week Flumarin 1000mg/Q8H WBC 7700 6330 Neu % 72.1 61 CRP 5.59 0.75

Flumarin 1000mg/Q8H + SABS 500mg One week Flumarin 1000mg/Q8H + SABS 500mg WBC 8280 5720 Neu % 73.4 63.3 CRP 1.45 2.26 Procalcitonin (PCT) [前降鈣素原檢查] 0.022 ng/ml [<0.046

WBC 5720 4280 Neu % 63.3 53.5 CRP 2.26 0.63

WBC 2.86 Neu % 54.9 CRP 0.5

7/07

9/30

Current complaint Perianal pain when stool passage

colon rectal injury after DCBS Incidence : 0.02-0.2% The most common: (high insertion of the rigid catheter and excessive inflation of the catheter balloon), ---- the perforation of the more vulnerable anterior part of the rectum. The second mechanism is perforation due to a weakened colonic mucosa (secondary to obstruction, diverticulitis, ischemic colitis, recent biopsies or old age)

In this case Need operation ? The timing of operation NPO period Delay complication

Classification 1.Perforations of the anal canal below the levator ani muscle 2. Incomplete perforations such as perforation of the rectal mucosa 3. Perforations into the retroperitoneum 4. Transmural perforations into the adjacent viscera 5. Perforations into the free intraperitoneal cavity. Peterson N, Rohrmann CA Jr, Lennard ES. Diagnosis and treatment of retroperitoneal perforation complicating the double-contrast barium-enema examination. Radiology 1982;144:249-52.

Free perforation into peritonium: mortality rate 35~50% Pathophysiology 1hr migration of polymorphonuclear cells 3hrs mononuclear cells appear 6hrs –3~5 days Fibrinous adhesions appear --leads to firm adhesions One month later, the barium particles are completely encapsulated by the surrounding tissues, and adhesions are firm and massive. After five months: Giant cells surround the encapsulated barium particles Free perforation into peritonium: mortality rate 35~50%

Review Dis Colon Rectum 2005; 49: 261–271

Treatment Intraperitoneal perforation: open lavage Fresh infralevator perforations with large mucosal lesions or anal sphincter lesions must be repaired Retroperitoneal perforation: conservative treatment ---Diverting colostomy + drainage(if toxic sign developed) Perirectal abscesses (ischiorectal/precoccygeal) require drainage. Rectosigmoid resection / primary anastomosis, and proximal colostomy

Late complication Stricture Chronic abscess formation --fistula formation Retroperitoneal fibrosis --paralytic ileus --ureteral obstruction-hydronephrosis

Thanks for your attention