Iatrogenic perforation at colonic imaging

A Case of Self-Induced Hydrostatic Colonic Perforation

Introduction: Constipation is a common complaint. The elderly are five times more prone to constipation than young people because of the effects of medication, immobility, and a blunted urge to defecate. Many of these patients are demented, have cognitive deficits, or suffer from a psychiatric disorder.

Colonic perforation caused by hydrostatic pressure is rare, and this typically occurs during fluoroscopic studies resulting when there is excessive intraluminal colonic pressure. Self-induced colonic perforation is even rarer.

Case report: We report the case of a 95-year-old man who presented to the emergency department with an acute surgical abdomen and symptoms of sepsis. He had a history of longstanding constipation. He gave a history of frequent insertion of a rubber hose into his anal canal to relieve his constipation while rinsing his anus after defecation. After resuscitation, an emergency operation was performed, and sigmoid colon perforation was found in addition to pre-existing diverticular disease. Hartmann’s procedure was performed after abdominal washout. Unfortunately, the patient died of multi-organ failure two days after surgery.

Conclusion: Self-induced hydrostatic colonic perforation is rare. The consequence is fatal, especially in the elderly or in cases of delayed presentation.

Practical gastrointestinal investigation of iron deficiency anaemia

About 10% of oesophagogastroduodenoscopies (OGDs) and colonoscopies are done for investigation of iron deficiency anemia (IDA) . Much of the existing guidance on investigation of IDA predates CRC screening, which has driven significant improvements in colonoscopy quality and completion rates, as well as a reduction in Helicobacter pylori prevalence and increase in PPI usage, and therefore probably needs re-consideration. New investigations, e.g. CT colonography, enteroscopy and capsule endoscopy have also been introduced. Areas covered: This review updates the approach to practical investigation of IDA. Medline was searched using the terms iron deficiency AND anemia AND/OR gastroscopy, colonoscopy, capsule and enteroscopy, together with review of recent relevant published abstracts on the topic. Expert commentary: Gastrointestinal pathology is now a more common cause of IDA than upper GI causes, reflecting better colonoscopy accuracy and completion rates as well as changing disease patterns, and carcinomas are more likely cause IDA than benign adenomas. Increasing use of antiplatelet and anticoagulants is driving greater presentation of IDA. Capsule endoscopy, enteroscopy and CT colonography are increasingly used. Fecal occult blood testing may be a useful simple screening method in the frail, as a negative test can avoid the need for invasive tests.

Neutropenic enterocolitis

Neutropenic colitis is a severe condition usually affecting immunocompromised patients. Its exact pathogenesis is not completely understood. The main elements in disease onset appear to be intestinal mucosal injury together with neutropenia and the weakened immune system of the afflicted patients. These initial conditions lead to intestinal edema, engorged vessels, and a disrupted mucosal surface, which becomes more vulnerable to bacterial intramural invasion. Chemotherapeutic agents can cause direct mucosal injury (mucositis) or can predispose to distension and necrosis, thereby altering intestinal motility. This article aims to review current concepts regarding neutropenic colitis’ pathogenesis, diagnosis, and management.

The Association Between Barium Examination and Subsequent Appendicitis: A Nationwide Population-Based Study

OBJECTIVE

The incidence and association between appendicitis and barium examination (BE) remain unclear. Such potential risk may be omitted. We conducted a longitudinal, nationwide, population-based cohort study to investigate the association between BE and appendicitis risk.

METHODS

From the Taiwan National Health Insurance Research Database, a total of 24,885 patients who underwent BE between January 1, 2000 and December 31, 2010 were enrolled in a BE cohort; an additional 98,384 subjects without BE exposure were selected as a non-BE cohort, matched by age, sex, and index date. The cumulative incidences of subsequent appendicitis in the BE and non-BE cohorts were assessed using the Kaplan-Meier curves and log-rank test. Cox proportional hazards regression analyses were employed to calculate the appendicitis risk between the groups.

RESULTS

The cumulative incidence of appendicitis was higher in the BE cohort than in the non-BE cohort (P = .001). The overall incidence rates of appendicitis for the BE and non-BE cohorts were 1.19 and 0.80 per 1000 person-years, respectively. After adjustment for sex, age, and comorbidities, the risk of appendicitis was higher in the BE cohort (adjusted hazard ratio = 1.46, 95% confidence interval = 1.23-1.73) compared with the non-BE cohort, especially in the first 2 months (adjusted hazard ratio = 9.72, 95% confidence interval = 4.65-20.3).

CONCLUSIONS

BE was associated with an increased, time-dependent appendicitis risk. Clinicians should be aware of this potential risk to avoid delayed diagnoses.

The safety of same-day CT colonography following incomplete colonoscopy with polypectomy

BACKGROUND

Concerns about the risk of bowel perforation for same-day computed tomography colonography (CTC) following an incomplete colonoscopy with polypectomy may lead to unnecessarily postponing the CTC.

OBJECTIVE

The objective of this article is to describe the complications including colon perforations associated with same-day CTC in a cohort who had polypectomies but an incomplete colonoscopy.

DESIGN

We conducted a retrospective study.

SETTING

Our study took place in a single, tertiary referral center.

PATIENTS

We studied consecutive patients who had CTC the same day as an incomplete colonoscopy with polypectomy.

INTERVENTIONS

Interventions included optical colonoscopy (OC), endoscopic polypectomies, and same-day CTC.

MAIN OUTCOME MEASUREMENTS

Our main outcome measurements included perforation rate with long-term follow-up.

RESULTS

A total of 3% of patients undergoing colonoscopy from January 2008 to December 2012 had same-day CTC following incomplete OC, and 72 polypectomies were performed in 34 (or 17%) of these patients. Incomplete colonoscopies were due to colon tortuosity and looping (25), severe angulations (five), colon mass (two), colon stenosis (one), bradycardia (one). Fifty-three percent of the OCs were screening for colon neoplasia, 29% diagnostic and 18% were surveillance of colon polyps. Most polyps were ≤ 5 mm, and found in the left colon. There were no reported complications or perforations associated with same-day CTCs during short- and long-term follow-up.

LIMITATIONS

Limitations of our analysis included retrospective single-center design, small number of patients for the occurrence, referral to same-day CTC was not standardized, inability to establish safety of CTC for specific scenarios such as after complex polypectomies, strictures, or advanced IBD.

CONCLUSIONS

Radiologists' apprehension to perform a CTC the same day as an incomplete colonoscopy following polypectomies because of perceived risk of perforation may be unfounded. More data are needed to determine the safety of same-day CTC in patients with high-risk findings during colonoscopy such as a stricture, severe IBD, and after complex polypectomies.

Proper management for morbid iatrogenic retroperitoneal barium insufflation

A barium enema is a diagnostic and therapeutic procedure commonly used for colon and rectum problems. Rectal perforation with extensive intra- and/or extraperitoneal spillage of barium is a devastating complication of a barium enema that leads to a significant increase in patient mortality. Due to the low number of reported cases in recent scientific literature and the lack of experience with the management of these cases, we would like to present our treatment approach to a rare case of retroperitoneal contamination with barium, followed by its intraperitoneal involvement during a diagnostic barium enema. Our experience with long-term management of the patient and the good outcome will be depicted in this paper.

[Optical colonoscopy and virtual colonoscopy: the current role of each technique]

The importance of optical or conventional colonoscopy in diagnosing colon disease is undisputed. In this context, optical colonoscopy is the gold standard against which other techniques must be validated. Apart from enabling direct inspection of the colonic mucosa, optical colonoscopy enables biopsies and techniques to treat and prevent colorectal cancer. Virtual colonoscopy or CT colonography has been validated in multicenter studies; virtual colonoscopy is as sensitive as optical colonoscopy for the detection of polyps and colon cancer. It is currently the only valid alternative to optical colonoscopy. Its role in patients with medium or high risk of colon cancer is in the process of being defined as multidisciplinary teams gain experience. This article aims to discuss the usefulness of virtual colonoscopy in different clinical situations, emphasizing the situations in which there is enough scientific evidence, and to discuss the controversies surrounding its possible use for population-based screening.

Perforation rate in CT colonography: a systematic review of the literature and meta-analysis

PURPOSE

The primary aim was to assess the perforation rate of CTC; the secondary aim was to identify potential clinical/technical predictors of this complication.

METHODS

Methods for analysis were based on PRISMA (preferred reporting items for systematic reviews and meta-analyses). From the selected studies, the rate of CTC perforation and patient/technical characteristics potentially associated with this event were extracted. Forest plots showing individual and pooled estimates of the perforation rate were obtained for all analyses. I(2) was used to evaluate heterogeneity between studies.

RESULTS

Eleven articles out of the 187 initially identified were selected for the analysis (103,399 patients). There were 29,048 (28%) asymptomatic individuals and 30,773 (30%) symptomatic patients; this characteristic was not reported in the remaining subjects (42%). Colon distension was obtained manually in 69,222 (67%) and using an automated carbon dioxide insufflator in 26,479 (26%) patients; in the remaining 7% of patients, this information was missing. Twenty-eight colonic perforations were reported, with the CTC perforation rate estimated to be 0.04% (95% CI. 0.00-0.10), 19-fold higher in symptomatic than in screening subjects (OR: 19.2, CI 3.3-108 and P = 0.001). The surgical rate was 0.008%. No CTC-related deaths were reported.

CONCLUSIONS

The perforation rate in CTC is very low, particularly considering asymptomatic individuals.

KEY POINTS

• This is the first meta-analysis on this topic, based on 100,000 patients. • The CTC-related colorectal perforation rate is 0.04%, 0.02% in asymptomatic subjects. • The CTC-induced surgery rate is 0.008% (1:12,500). • The perforation rate in CTC is low, particularly in average-risk, asymptomatic individuals.

Colorectal cancer screening in an equal access healthcare system

INTRODUCTION

The military health system (MHS) a unique setting to analyze implementation programs as well as outcomes for colorectal cancer (CRC). Here we look at the efficacy of different CRC screening methods, attributes and results within the MHS, and current barriers to increase compliance.

MATERIALS AND METHODS

A literature search was conducted utilizing PubMed and the Cochrane library. Key-word combinations included colorectal cancer screening, racial disparity, risk factors, colorectal cancer, screening modalities, and randomized control trials. Directed searches were also performed of embedded references.

RESULTS

Despite screening guidelines from several national organizations, extensive barriers to widespread screening remain, especially for minority populations. These barriers are diverse, ranging from education and access problems to personal beliefs. Screening rates in MHS have been reported to be generally higher at 71% compared to national averages of 50-65%.

CONCLUSION

CRC screening can be highly effective at improving detection of both pre-malignant and early cancers. Improved patient education and directed efforts are needed to improve CRC screening both nationally and within the MHS.

Rectal perforations and fistulae secondary to a glycerin enema: Closure by over-the-scope-clip

Rectal perforations due to glycerin enemas (GE) typically occur when the patient is in a seated or lordotic standing position. Once the perforation occurs and peritonitis results, death is usually inevitable. We describe two cases of rectal perforation and fistula caused by a GE. An 88-year-old woman presented with a large rectal perforation and a fistula just after receiving a GE. Her case was further complicated by an abscess in the right rectal wall. The second patient was a 78-year-old woman who suffered from a rectovesical fistula after a GE. In both cases, we performed direct endoscopic abscess lavage with a saline solution and closed the fistula using an over-the-scope-clip (OTSC) procedure. These procedures resulted in dramatic improvement in both patients. Direct endoscopic lavage and OTSC closure are very useful for pararectal abscess lavage and fistula closure, respectively, in elderly patients who are in poor general condition. Our two cases are the first reports of the successful endoscopic closure of fistulae using double OTSCs after endoscopic lavage of the debris and an abscess of the rectum secondary to a GE.