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David Zula
Monash Health Network, Australia
Posters & Accepted Abstracts: J Hepato Gastroenterol
A 59-year-old female presented with anorectal pain and bright red per rectal (PR) bleeding post self-administration of rectal water enemas. Her history was significant for hypothyroidism and dyslipidaemia. On examination she was heaodynamicaly stable, with a soft abdomen and trace PR blood on digital rectal exam, and was discharged home without further investigation. She represented six days later febrile to 39°C, with anorectal pain. On examination she was tender to the lower abdomen with no peritonism, and no blood on PR exam. Pathology indicated raised inflammatory markers and so a computed tomography (CT) scan was obtained, which revealed a 64 x 47 x 66 mm peripherally enhancing fluid and gas containing collection in the pouch of Douglas, consistent with an abscess, and concerning for a rectal perforation. Intraoperatively, bimanual examination raised suspicion for a low rectal perforation with fluctuance on the anterior rectal wall. Flexible sigmoidoscopy confirmed a <1 cm mucosalsealed left anterior rectal wall perforation six centimetres from the anal verge. At laparoscopy, an extraperitoneal pelvic collection at the rectovaginal septum was noted with a bulging necrotic capsule that was drained with an intra-peritoneal drain, and the patient was defunctioned with a loop ileostomy. Rectal enema usage is common place, and perforation is exceptionally rare. However, the mortality from rectal perforation is dangerously high. With few specific clinical signs, and radiological findings only evident after ~48 hours, a high index of clinical suspicion is imperative. Early examination under anaesthetic and proximal diversion remains the mainstay of initial treatment.
David Zula is a General Surgical Registrar at the Monash Health Network, in Melbourne Australia. He has a keen interest in the Colorectal Subspecialty and a passion for academic surgery. As a comity member for the Monash Surgical Research Group, he helps coordinate various projects within Monash Health, working closely with the CSSANZ accredited Colorectal Department at Monash Health.
