Indwelling bowel management system as a cause of life-threatening rectal bleeding

The crucial role of fecal management systems in intensive care

INTRODUCTION

Patients in intensive care units (ICUs) frequently lose control over their fecal continence leading to fecal incontinence (FI). We provide an overview of existing medical devices, which are supposed to alleviate FI-related problems.

AREAS COVERED

Fecal management systems (FMS) prevent infections and complications. They reduce the risk of pressure ulcers and fecal incontinence. The systems enhance patient comfort and mitigate emotional distress during illness. Furthermore, FMS facilitate nursing care by reducing the incontinence-related workload. Finally, these systems can help minimize treatment costs by preventing complications, and reduction of extended hospital stays and additional treatments. Several well accepted systems made of silicone are on the market. A polyurethane-based soft balloon FMS (hygh-tec® basic-plus) has also been introduced, offering more comfort to the patient, safer handling for the healthcare professionals, and provides reliable leakproof access to the patient's colon. In addition to contamination-free fecal diversion, the trans-anal sealing mechanism of the device also allows for irrigation and delivery of medication into the colon.

EXPERT OPINION

FMS in ICUs are integral to patient care and dignity. Recognizing and prioritizing the importance of these systems is essential for providing the highest standard of care to critically ill patients in the ICU.

Clinical and Health Economic Evaluation of a Novel Device for Fecal Management in Bedridden Patients

Purpose

To evaluate the clinical effectiveness and health economic benefits of a novel indwelling lattice-based device for fecal management in bedridden patients.

Materials and methods

This nonrandomized, two-arm study included 70 bedridden patients (≥18 years exhibiting liquid stool) referred from the ICU of surgery and medicine units of a 2000-bed tertiary care referral hospital, assigned to the intervention and control groups. About 35 patients were eligible to be included in the intervention group while 35 patients with contraindications to the intervention device were included in the usual care control group. Assessments were made before and every 24 hours during the study, and all patients were closely monitored for development of incontinence-associated dermatitis (IAD) and hospital-acquired pressure injury.

Results

The test device was successfully deployed on the first attempt and effectively diverted fecal matter in all 35 patients, with no adverse events. In the control group, 83% of the patients developed IAD, which resulted in prolonged hospitalization and increased expenses. Overall, the control group (with adult diapers) required greater time, resources, and efforts for fecal management and resulted in increased patient morbidity.

Conclusion

The patient management time, resource consumption, overall cost of hospital admission, and the complication rates are significantly lower with the use of the novel lattice-based device than with the use of adult diapers for fecal management.

How to cite this article

Sheth H, Rao S, Karthik V. Clinical and Health Economic Evaluation of a Novel Device for Fecal Management in Bedridden Patients. Indian J Crit Care Med 2023;27(10):759-765.

Incidence and Characterization of Rectal Complications From Fecal Management Systems

BACKGROUND

Fecal management systems have become ubiquitous in hospitalized patients with fecal incontinence or severe diarrhea, especially in the setting of perianal wounds. Although fecal management system use has been shown to be safe and effective in initial series, case reports of rectal ulceration and severe bleeding have been reported, with a relative paucity of clinical safety data in the literature.

OBJECTIVE

The purpose of this study was to determine the rate of rectal complications attributable to fecal management systems, as well as to characterize possible risk factors and appropriate management strategies for such complications.

DESIGN

This was a retrospective cohort study.

SETTINGS

The study was conducted at a large academic medical center.

PATIENTS

All medical and surgical patients who underwent fecal management system placement from December 2014 to March 2017 were included.

MAIN OUTCOME MEASURES

We measured any rectal complication associated with fecal management system use, defined as any rectal injury identified after fecal management system use confirmed by lower endoscopy.

RESULTS

A total of 629 patients were captured, with a median duration of fecal management system use of 4 days. Overall, 8 patients (1.3%) experienced a rectal injury associated with fecal management system use. All of the patients who experienced a rectal complication had severe underlying comorbidities, including 2 patients on dialysis, 1 patient with cirrhosis, and 3 patients with a recent history of emergent cardiac surgery. In 3 patients the bleeding resolved spontaneously, whereas the remaining 5 patients required intervention: transanal suture ligation (n = 2), endoscopic clip placement (n = 1), rectal packing (n = 1), and proctectomy in 1 patient with a history of pelvic radiotherapy.

LIMITATIONS

The study was limited by its retrospective design and single institution.

CONCLUSIONS

This is the largest study to date evaluating rectal complications from fecal management system use. Although rectal injury rates are low, they can lead to serious morbidity. Advanced age, severe comorbidities, pelvic radiotherapy, and anticoagulation status or coagulopathy are important factors to consider before fecal management system placement. See Video Abstract at http://links.lww.com/DCR/B698.

INCIDENCIA Y CARACTERIZACIN DE LAS COMPLICACIONES RECTALES DE LOS SISTEMAS DE MANEJO FECAL

ANTECEDENTES:Los sistemas de manejo fecal se han vuelto omnipresentes en pacientes hospitalizados con incontinencia fecal o diarrea severa, especialmente en el contexto de heridas perianales. Aunque se ha demostrado que el uso del sistema de tratamiento fecal es seguro y eficaz en la serie inicial, se han notificado casos de ulceración rectal y hemorragia grave, con una relativa escasez de datos de seguridad clínica en la literatura.OBJETIVO:Determinar la tasa de complicaciones rectales atribuibles a los sistemas de manejo fecal. Caracterizar los posibles factores de riesgo y las estrategias de manejo adecuadas para tales complicaciones.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro médico académico de mayor volumen.PACIENTES:Todos los pacientes médicos y quirúrgicos que se sometieron a la colocación del sistema de manejo fecal desde diciembre de 2014 hasta marzo de 2017.PRINCIPALES MEDIDAS DE VALORACION:Cualquier complicación rectal asociada con el uso del sistema de manejo fecal, definida como cualquier lesión rectal identificada después del uso del sistema de manejo fecal confirmada por endoscopia baja.RESULTADOS:Se identificaron un total de 629 pacientes, con una duración media del uso del sistema de manejo fecal de 4,0 días. En general, 8 (1,3%) pacientes desarrollaron una lesión rectal asociada con el uso del sistema de manejo fecal. Todos los pacientes que mostraron una complicación rectal tenían comorbilidades subyacentes graves, incluidos dos pacientes en diálisis, un paciente con cirrosis y tres pacientes con antecedentes recientes de cirugía cardíaca emergente. En tres pacientes el sangrado se resolvió espontáneamente, mientras que los cinco pacientes restantes requirieron intervención: ligadura de sutura transanal (2), colocación de clip endoscópico (1), taponamiento rectal (1) y proctectomía en un paciente con antecedentes de radioterapia pélvica.LIMITACIONES:Diseño retrospectivo, institución única.CONCLUSIONES:Este es el estudio más grande hasta la fecha que evalúa las complicaciones rectales del uso del sistema de manejo fecal. Si bien las tasas de lesión rectal son bajas, pueden provocar una morbilidad grave. La edad avanzada, las comorbilidades graves, la radioterapia pélvica y el estado de anticoagulación o coagulopatía son factores importantes a considerar antes de la colocación del sistema de manejo fecal. Consulte Video Resumen en http://links.lww.com/DCR/B698.

Rectovaginal Fistula as a Complication of Fecal Management System

We report a rare complication of the use of an intrarectal catheter. An 18-year-old female with T-cell acute lymphoblastic leukemia post-matched unrelated donor allogeneic stem cell transplantation (auto-SCT) developed hepatic encephalopathy secondary to hepatic sinusoidal obstructive disease. A fecal management system was used to contain and divert fecal matter in this immobilized patient. Approximately 1 month after placement of an intrarectal catheter, stool was noted in the vaginal vault. Speculum examination confirmed development of a rectovaginal fistula.

Faecal incontinence: investigation, treatment and management

Faecal incontinence (FI) is a hidden problem that is under-diagnosed, under-investigated and under treated. Up to 10% of adults can experience an episode of FI. The prevalence of FI in the adult population has been estimated at 0.8-6.2%. Recent North American research indicates a prevalence of 8.3% in adults living in the community. This article explores the reasons why adults can develop FI, the importance of assessment, what treatments are available and how intractable FI can best be managed.

The Traumatic Tube: Bleeding Rectal Ulcer Caused by Flexi-Seal Device

Diarrhea and fecal incontinence are common in critically ill patients and present a challenging problem in patient management. The Flexi-Seal® Fecal Management System is a device to divert the stools away from the patient, thus improving the care to patients with fecal incontinence. There have been only few case reports describing the complications with the use of this device. Here, we present a case of a 77-year-old woman who was admitted due to massive hematochezia while on anticoagulation. She was found to have a large rectal ulcer caused by the Flexi-Seal device, used during the last hospital stay for fecal incontinence. Flexi-Seal device can be effective for the management of incontinence; however, caution should be exercised during handling and pressure from the retention balloon should be relieved periodically.

Nonsurgical faecal diversion in the management of severe perianal sepsis: a retrospective evaluation of the flexible faecal management system

INTRODUCTION

Severe perianal sepsis is often difficult to manage after surgical debridement due to faecal contamination. Diversion of the faecal stream has been attempted with faecal pouches and rectal tubes, and in some cases, a diverting stoma is created. However, reversal of the stoma may be delayed due to prolonged sepsis and this is not without risks. Herein, we review the use of a flexible faecal management system in patients with severe perianal sepsis.

METHODS

We retrospectively evaluated 15 patients who made use of the ConvaTec Flexi-Seal® Fecal Management System (FMS) between 1 January 2007 and 31 December 2010. The demographics and comorbidities of the patients, as well as the treatment received, were recorded and reviewed.

RESULTS

None of the patients required the creation of a stoma to divert the faecal stream. Nursing requirements and wound care were found to be improved with the use of the Flexi-Seal® FMS (fewer changes were needed). No severe complications were observed in our series. Two deaths were encountered, but the cause of death was not directly due to the initial perianal sepsis. Overall, the wound healing rate was 80.0%, with one graft failure (11.1%).

CONCLUSION

The use of the Flexi-Seal® FMS in patients with perianal sepsis following extensive debridement is feasible and can be considered before stoma creation.

Rectourethral fistula secondary to a bowel management system

A 67-year-old Caucasian male was admitted under the vascular team with critical lower limb ischaemia. Bypass surgery was performed and he was admitted to the intensive care unit post-operatively. The patient experienced a turbulent post-operative recovery complicated by pneumonia, poor respiratory wean and faecal incontinence. A bowel management system was inserted but after 18 days it was reported faecal matter was bypassing his catheter. A CT scan demonstrated an area of necrosis where the bowel management system had been sited which formed a rectourethral fistula. Bowel management systems are frequently used in intensive care unit settings where a high proportion of patients suffer from faecal incontinence. If used correctly they can reduce skin contamination, infection and maintain patient hygiene. However, appropriate assessment and investigations should be addressed before inserting such devices. This case report highlights serious adverse effects of these devices and describes the first documented case of these devices causing a rectourethral fistula.

Massive gastrointestinal hemorrhage as a complication of the Flexi-Seal fecal management system

Use of the Flexi-Seal fecal management system, a safe and effective means of fecal diversion in patients with fecal incontinence and diarrhea, can be associated with rare, life-threatening complications. For example, a critically ill patient had 2 episodes of massive rectal bleeding associated with use of the system that required transfusion of blood products. Hemorrhage was controlled during the first episode by angiography with selective coil embolization; the second required colonoscopy with suture ligation of the affected lesion. A literature review revealed 9 other cases that were managed endoscopically, surgically, or with angiography. Although none of the patients died, they experienced obvious complications that required transfusion of blood products, endoscopy, surgery, use of conscious sedation or general anesthesia, angiography, and exposure to intravenous contrast material. Patients receiving therapeutic doses of anticoagulation and antiplatelet drugs, which may precipitate or aggravate hemorrhaging, are particularly at risk for complications with the Flexi-Seal system.

Common anorectal disorders for the intensive care physician

Although anorectal disorders such as abscess, fissure, and hemorrhoids are typically outpatient problems, they also occur in the critically ill patient population, where their presentation and management are more difficult. This article will provide a brief review of anorectal anatomy, explain the proper anorectal examination, and discuss the current understanding and treatment concepts with regard to the most common anorectal disorders that the intensive care unit clinician is likely to face.

A case of pressure ulceration and associated haemorrhage in a patient using a faecal management system

Diarrhoea is a difficult patient problem to manage in the intensive care setting, causing odour, discomfort and embarrassment for the patient and potential for loss of skin integrity and cross contamination. Caring for these patients is resource-intensive. A recently developed product for the management of faecal incontinence is the Flexi-Seal Faecal Management System (FMS(©)). Whilst this product is usually effective for managing diarrhoea, there are uncommon but serious complications associated with its use. Rectal bleeding attributed to pressure ulceration of the rectal mucosa can be severe, especially in conjunction with the use of anticoagulation. We report a case of severe rectal bleeding requiring surgical intervention and administration of large amounts of blood products, caused by pressure ulceration as a result of the use of a Flexi-Seal FMS(©). The case report is followed by a review of the literature. Similar complications have been described by others. Although, based on the number of reported complications, the incidence of serious complications appears to be low, a publication bias cannot be ruled out. Knowledge of the complications associated with the device is important for evaluating the appropriateness of insertion and for ensuring the safe and effective on going care of patients using Flexi-Seal FMS(©).