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The increasing use of retroflexion proctoscopy to evaluate the distal rectum is not without complications. We report a series of three patients who experienced extraperitoneal rectal perforation secondary to retroflexion proctoscopy and discuss our success with conservative management. By evaluating each clinical situation individually and following certain principles, successful outcome can be achieved without surgical intervention. Success depends on several factors: 1) the injury must be below the peritoneal reflection; 2) the patient must have undergone a complete bowel preparation before endoscopy; 3) postinjury, the patient must continue to show no evidence of peritonitis or hemodynamic instability; and 4) the patient must be given nothing by mouth, started on intravenous antibiotics and possibly parenteral nutrition, and closely monitored with serial abdominal examinations. The presence of comorbid conditions does not necessarily diminish the chance that conservative therapy will succeed.
THE EVALUATION OF the distal rectum and anal canal with the standard anoscope has slowly been relegated to secondary importance with the advent of the flexible sigmoidoscope and the colonoscope. In many training programs, the technique of retroflexion of the endoscope within the rectal ampulla is being taught to view the distal rectum and proximal anal canal for benign as well as malignant disease. During the past 3 years, there have been three cases of rectal perforation secondary to retroflexion of the endoscope in our institution. All cases were treated conservatively. We are reporting our experience and discuss basic principles that will guide the clinician in managing similar cases. To our knowledge, there are no additional series of rectal perforation due to retroflexion in the literature. Retroflexion injury to the rectum should be added to the growing list of iatrogenic causes of rectal perforation injuries.
Case Reports
Case I
A 76-year-old female presented with a history of multiple episodes of bright red blood/rectum the night before admission. Her only additional complaints were lightheadedness and dizziness. Her past medical history was remarkable for two Caesarean sections, bilateral hip replacements, paroxysmal atrial tachycardia, myocardial infarction, and unstable angina. Her physical examination was otherwise unremarkable, except for heme-postive stool. Her admission chest and abdominal radiographs were noncontributory. Her admission laboratory values included a white blood cell (WBC) count of 8,OOO/cu mm, hematocrit 35 per cent, and platelet count of...