Creighton University Medical Center Omaha, NE, United States
Christopher Picking, MD1, Avanija Buddam, MBBS2, Subhash Chandra, MBBS2 1Creighton University Medical Center, Omaha, NE; 2Creighton University, Omaha, NE
Introduction: Anorectal manometry (ARM) with maximum tolerated volume (MTV) is a commonly utilized modality for assessing anal sphincter function as well as rectal pressure, sensation, and anorectal dyssynergia. Rectal perforation is a rare complication, with only 8 cases reported in the literature. Here we report a case of rectal perforation from anorectal manometry in a patient with a history of multiple pelvic surgeries.
Case Description/Methods: A 79-year-old Caucasian female experienced rectal perforation during anorectal manometry, performed in the work-up of fecal incontinence. Initial work-up included colonoscopy showing scattered sigmoid diverticula, as well as hemorrhoids on the perianal exam. Surgical history was significant for a total hysterectomy with bilateral oophorectomy, multiple bladder sling surgeries, and 3 vaginal deliveries without episiotomy. Two months after colonoscopy, ARM with MTV was performed. The sensation was noted at 40 ml, MTV at 80 ml, and the patient was not able to expel the rectal balloon in 2 minutes. Bleeding and abdominal pain were noted after the procedure which progressively worsened. A computed tomography scan showed extraperitoneal perforation of the rectum and so she was immediately taken to the operating room. Posterior distal rectal full-thickness perforation, 2 cm above the anal verge, 4x3 cm in size was noted on flex sigmoidoscopy, and significant intra-abdominal adhesions were noted on laparoscopy. Laparoscopic diverting loop ileostomy with lysis of adhesions was performed, and the patient was discharged 7 days later.
Discussion: After a review of available literature, underlying risk factors and warning signs for perforation are present throughout. In our case, the perforation was likely the result of tight angulation of the distal rectum, likely from multiple bladder incontinence surgeries. As rectal perforation is an exceedingly rare complication of ARM, risk factors and warning signs for perforation may not be recognized by those performing the procedure. The provided table identifies high-risk patients, allowing for increased caution when performing ARM. It also provides common warning signs that perforation has occurred, to not delay intervention.
Figure: Anorectal Manometry Data with CT evidence of Rectal Perforation
Most Significant Risk Factors For Rectal Perforation During ARM
Warning Signs That Perforation Has Occurred
History of low anterior resection and ileostomy reversal
Radiation around the rectum/lower abdomen
Multiparous females with multiple vaginal deliveries
Urinary incontinence surgeries
Presence of blood on the catheter after removal, or hematochezia soon thereafter
Audible pop or significant pain while obtaining MTV
Worsening abdominal pain during/following ARM
Sudden decrease in intra-balloon pressure while obtaining MTV
Very low MTV
Christopher Picking indicated no relevant financial relationships.
Avanija Buddam indicated no relevant financial relationships.
Subhash Chandra indicated no relevant financial relationships.
Christopher Picking, MD1, Avanija Buddam, MBBS2, Subhash Chandra, MBBS2. P0180 - Rectal Perforation; A Rare Complication From Anorectal Manometry: A Case Report and Literature Review, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.