https://orcid.org/0009-0007-2011-6763
Abstract
Unsupervised self-administered cleansing enemas pose a rare but catastrophic risk of colorectal perforation. We report a 71-year-old man presenting with acute peritonitis immediately after a self-enema for chronic constipation. Notably, he connected the enema hose directly to a household water tap, inadvertently introducing a large volume of water under high mains pressure. Radiography revealed pneumoperitoneum. Emergency laparotomy identified a 5-cm longitudinal blowout perforation on the mesenteric border of the sigmoid colon with fecal contamination. A Hartmann-type procedure (partial sigmoid resection with an end colostomy) was performed. Histopathology confirmed a structurally normal colonic wall devoid of underlying pathologies. The findings were consistent with massive hydrostatic pressure injury, likely exacerbated by distal fecal loading. The patient recovered uneventfully, with no complications at the 30-day follow-up. This case highlights the extreme danger of connecting enema devices directly to domestic water supplies and emphasizes prompt surgery for atypical barogenic perforations.
Introduction
Chronic constipation is a highly prevalent functional gastrointestinal disorder in the elderly, significantly impacting their quality of life and frequently leading to the use of over-the-counter laxatives or unsupervised enemas [1]. While complications such as ischemic stercoral perforation due to impacted fecalomas are well-documented [2], traumatic injuries directly resulting from retrograde enema administration are not rare and are associated with severe morbidity and mortality [3–5]. Colorectal perforations from enemas can occur mechanically from the rigid device tip or barogenically due to a sudden increase in intraluminal hydrostatic pressure [6, 7]. We present an unusual case of a severe barogenic sigmoid colon perforation located on the mesenteric border following a self-administered cleansing enema in a 71-year-old man.
Case report
A 71-year-old man presented to the emergency department exactly two hours after the sudden onset of severe, diffuse abdominal pain. The pain commenced immediately after the patient self-administered a cleansing enema at home. To perform the enema, the patient self-inserted the nozzle and connected the hose directly to a household bathroom water tap. He accidentally turned the tap on fully, introducing an uncontrolled, large volume of cold tap water under high mains pressure into his rectum. His medical history was significant for Ischemic Heart Disease (Stable Angina FC II), Stage 2 Hypertension, and Grade II Obesity (ASA Physical Status III). His routine home medications included daily antihypertensive drugs, antiplatelet therapy (Aspirin 75 mg), and frequent use of over-the-counter laxatives for chronic constipation.
On physical examination, the patient appeared distressed with a dry tongue and significant tachycardia (121 bpm). His abdomen was remarkably distended with diffuse tenderness and pronounced abdominal guarding, and prominent peritoneal signs indicative of acute generalized peritonitis. Laboratory investigations revealed a white blood cell count of 5.6 × 109/L. The absence of marked leukocytosis can be observed in elderly patients despite severe peritonitis. An initial abdominal ultrasound revealed free fluid in the peritoneal cavity. Subsequently, an upright abdominal radiograph demonstrated free gas under the diaphragm, confirming a hollow viscus perforation (Fig. 1).
An erect plain abdominal radiograph demonstrating pneumoperitoneum, visualized as free air accumulated beneath the dome of the diaphragm (arrow).
The patient was immediately resuscitated and taken for an emergency laparotomy. Intraoperative exploration revealed gross fecal contamination of the peritoneal cavity and a 5-cm longitudinal tear situated exclusively on the mesenteric border of the sigmoid colon (Fig. 2).
Intraoperative view of the sigmoid colon lesion demonstrating a 5-cm longitudinal tear along the mesenteric border (arrow).
Due to the extent of the fecal peritonitis and the large defect, the patient underwent a Hartmann-type procedure (partial sigmoid resection with an end colostomy and closure of the distal sigmoid stump). Extensive peritoneal lavage with copious amounts of warm normal saline was performed, a pelvic drain was placed, and broad-spectrum intravenous antibiotics were administered postoperatively. Gross examination of the resected colonic specimen revealed a macroscopically healthy colonic wall (Fig. 3). Subsequent microscopic histopathological analysis confirmed this finding, explicitly demonstrating the absence of diverticulitis, ischemic necrosis, malignancy, stercoral ulceration, or any underlying chronic inflammatory disease.
Gross examination of the resected colonic specimen showing sharp, clean margins without diverticulosis or masses (macroscopically healthy colonic wall).
The tear margins were sharp and clean, with no underlying pathological weaknesses such as diverticulosis, stercoral ulceration, ischemic necrosis, or neoplastic masses. His postoperative course was uneventful, and he was discharged on the 8th postoperative day. At the 30-day follow-up, the patient exhibited no wound or stoma complications, required no readmissions, and colostomy reversal was planned for 6 months post-surgery.
Discussion
Colonic perforation is a catastrophic clinical event that can arise spontaneously from underlying inflammatory and structural diseases such as collagenous colitis [8], acute febrile illnesses in pediatric populations [9], severe amebiasis [10], or as a complication of adjacent organ inflammation like necrotizing pancreatitis [11]. In the elderly population, chronic constipation alone can lead to ischemic necrosis and stercoral perforation, typically occurring on the more vulnerable antimesenteric border of the rectosigmoid region [1, 2]. However, traumatic perforations from self-administered enemas present a distinct and preventable clinical entity [4, 12].
Unsupervised enema administration poses significant risks, often exacerbated by patient ignorance regarding proper indications and techniques [3, 5]. Injuries generally manifest either as direct mechanical penetrations from the enema nozzle-often localized to the anterior wall of the rectum [12]-or as barogenic ruptures caused by excessive hydrostatic pressure within the bowel [6, 7]. In our patient, the complete absence of lower rectal mucosal injury and the presence of a massive longitudinal tear higher up in the sigmoid colon strongly point to a barogenic etiology. The findings were most consistent with massive hydrostatic pressure injury, likely exacerbated by distal fecal loading. By connecting the enema hose directly to a water tap, the patient introduced fluid at a pressure significantly exceeding the elasticity threshold of the colonic wall.
The sigmoid colon is an uncommon site for enema-induced injuries, accounting for only 9.5% of documented cases, whereas the vast majority occurs in the rectum [6]. Furthermore, pressure-induced bowel ruptures predominantly occur along the antimesenteric edge, where the colonic wall is traditionally thinner and lacks mesenteric support [2, 6]. A longitudinal perforation isolated entirely on the mesenteric border of a structurally healthy colon, particularly induced by hydrostatic enema irrigation, remains exceedingly rare [7]. The clean tear margins and absence of underlying diverticular or stercoral disease confirmed that the rupture was purely pressure-induced.
Management of colorectal perforations depends on the degree of peritoneal contamination, the size of the defect, and the patient’s haemodynamic stability [12]. While some isolated, extraperitoneal rectal injuries might be managed conservatively [12], free intraperitoneal ruptures with fecal contamination demand immediate surgical intervention [6]. As demonstrated in similar high-risk scenarios, delays in treatment inevitably lead to progressive peritonitis, septicemia, and mortality [3, 5]. Prompt diagnostic recognition via erect radiography or computed tomography, followed by a damage-control surgical approach-involving resection and fecal diversion-is paramount to mitigating the critical risks of fecal peritonitis and ensuring patient survival [6, 11].
In conclusion, colorectal perforation induced by a self-administered enema is a rare but life-threatening surgical emergency. This case underscores that sudden barogenic trauma can cause an extensive mesenteric border rupture even in a structurally healthy sigmoid colon. Early clinical recognition, prompt radiological imaging, and immediate surgical intervention utilizing damage-control principles are critical to managing severe fecal peritonitis and ensuring patient survival. Furthermore, this report highlights the pressing need for patient education regarding the potential catastrophic risks associated with unsupervised retrograde enemas.
Acknowledgements
Not applicable.
Author contributions
Conceptualization: F.G.B., Y.I.N., and N.Y.B. Collected consent and data: F.G.B., Y.I.N., N.Y.B, Z.I.U., and G.P.R. Contributing author: F.G.B. Supervision and acquisition of ethical approval: F.G.B and N.Y.B. Writing—original draft: F.G.B., Y.I.N., and Z.I.U. Writing final manuscript edition: F.G.B., Y.I.N., N.Y.B., Z.I.U., and G.P.R.
Conflicts of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Funding
This research received no external funding.
Data availability
All data generated or analyzed during this study are included in this published article.
Ethical approval
Ethical approval for this work was obtained from the Ethics Committee of the Tashkent State Medical University in 2026.
Informed consent
Written informed consent was obtained from the patient for the publication of this case report and any accompanying clinical and radiological images.
