Accidental Intrarectal Administration of Alcohol Enema Induces Proctocolitis and Fecal Incontinence

Table of Contents

At 2 hours before an elective colonoscopy indicated for abdominal pain in a 67-year-old woman, the patient’s sister wrongly administered 250 cm³ of “cleansing enema” containing ethyl alcohol 96 %. The patient experienced a perineal and anorectal burning pain, severe abdominal pain, profuse and involuntary diarrhea, tenesmus, rectal bleeding, and the emission of numerous white plaques mixed with and all over the liquid feces. We diagnosed a severe colonic mucosal sloughing with a possible secondary perforation. A conservative treatment was prescribed of intravenous fluids and electrolytes, and intravenous cefotaxime, metronidazole, and analgesics. We had no evidence-based reasons to prescribe her steroids, so we treated our patient’s acute proctocolitis as an ischemic colitis.

After 24 hours, we performed a careful flexible colonoscopy (Figures [1] and [2]). For the next 7 days, the patient improved with less abdominal pain, lack of peritonism signs and no bleeding, the diarrhea stopped and she was able to eat and move almost normally. She continued outpatient treatment comprising of oral antibiotics for a further 7 days. Fecal incontinence was the last symptom to disappear, by the 3rd week.

A month later, when she was symptomless, we performed a total colonoscopy and observed only a mild patchy erythema on rectal and sigmoid mucosa, no white plaques, no stenosis, and many small noncomplicated colon diverticula mainly distributed in the sigmoid colon. At the last visit, 1 year later, the patient was completely asymptomatic and there were no inflammatory features at colonoscopy.

Figure 1Colonoscopy revealed confluent white plaques adherent to underlying distal rectal mucosa and covering partially the anal canal and perianal epidermis. The fecal incontinence was extremely severe, and occurring when the patient was upright

Figure 2Proximal rectal mucosa showed a severe erythema and mucosal denudation, probably as a result of the rectal bleeding and the detachment of fibrin white plaques overlying a few hours before

Acute colitis has been described after rectal instillation of detergent or chemical substances [1] [2] . This is the fourth case reported in medical literature referenced in Medline of alcohol-induced proctitis involving ethyl alcohol [3] [4] [5] . Our case is the first to describe fecal incontinence that occurred as the result of an accidental ethyl alcohol enema administered prior to an elective colonoscopy.

It is possible that these accidental instillations occur more frequently in clinical practice but to a less severe degree, probably because patients notice perineal burning initially and quickly remove the cleansing enema. We think endoscopic follow-up should not take place until at least 3 weeks after alcohol instillation, as a perforation could occur if a colonoscopy is done with normal insufflation. Our case shows the endoscopic features and clinical manifestations of alcohol-induced functional and structural damage to the anus, rectum and colon, with complete resolution after conservative treatment.

References

• 1 Jonas G, Mahoney A, Murray J, Gertler S.. Chemical colitis due to endoscope cleaning solutions: a minic of pseudomembranous colitis.  Gastroenterology. 1988;  95 1403
• 2 Davila A D, Willenbucher R F.. Other diseases of the colon and rectum: melanosis coli, cathartic colon, and soap or chemical colitis. In: Feldman M, Sleisenger MH, Scharschmitt B (eds). Sleisenger and Fordtran’s gastrointestinal and liver disease.  Philadelpha; Saunders, 1998: 1992-1995
• 3 Herrerias J M, Muniain M A, Sanchez S, Garrido M.. Alcohol-induced colitis.  Endoscopy. 1983;  15 121-122
• 4 Bhalotra R.. Alcohol-induced proctitis in a human.  J Clin Gastroenterol. 1988;  10 592
• 5 Triantafillidis J K, Vekini J, Nicolakis D, Emmanouilides A.. Ethanol-induced proctitis: another kind of chemical proctitis.  Am J Gastroenterol. 1994;  89 1270-1271