Chi Fai Tsang

Hypertonic sodium phosphate enemas can be effective and are commonly used to treat constipation in both hospital and community
settings. While they are over-the-counter medicine in Australia, the adverse effects, though rare, can cause significant morbidity and
mortality of patients. The most common adverse effects are water electrolyte disturbance. Meanwhile, rectal enema injury can be
the consequence of the initial mucosal laceration from the tip of the nozzle. The extravasation of the hypertonic phosphate solution
can exacerbate mucosal necrosis, and subsequently cause localized perforation. Only a small handful of case series of perforation
of rectum and sigmoid colon caused by enemas have been reported, but it can be catastrophic. This case series demonstrates two
rare cases of enema-related complications. More importantly, it highlights the importance of a careful clinical history, examination, and
suspicion for patients who present with abdominal pain, rectal bleeding, and fevers, especially in the context of recent administration
of enemas. In addition, CT evident extraluminal air is the hallmark finding of perforation of the rectosigmoid colon. Failure to appreciate
the symptoms and signs of rectal injury can potentially result in delay in the initiation of appropriate medical and surgical treatments.


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