Caustic colitis due to formalin enema

Chemical colitis

Chemical colitis can occur as a result of accidental contamination of endoscopes or by intentional or accidental administration of enemas containing various chemicals. Most cases have occurred after accidental contamination of endoscopes with glutaraldehyde and/or hydrogen peroxide. There have been multiple case reports of chemical colitis resulting from unintentional administration of caustic chemicals. Intentional administration of corrosive enemas has been implicated in sexual practices, bowel cleansing, or in suicide attempts. Patients present with nonspecific symptoms including abdominal pain, rectal bleeding, and/or diarrhea. As chemical colitis remains rare, the literature consists of scattered case reports and small series. Agents implicated in chemical colitis that are covered in this review include alcohol, radiocontrast agents, glutaraldehyde, formalin, ergotamine, hydrofluoric acid, sulfuric acid, acetic acid, ammonia, soap, sodium hydroxide, hydrogen peroxide, herbal medicines, chloro-m-xylenol, and potassium permanganate. Clinical, endoscopic, and histologic features are outlined for each agent in addition to the existing literature. Given the nonspecific presentation of many cases of chemically induced colitis, the diagnosis can be challenging if the pertinent history is not obtained. Most patients demonstrate the resolution of chemical-induced colitis after conservative or medical therapy. Depending on the depth and extent of injury, patients rarely require colectomy for ischemic colitis and/or peritonitis. Other postingestion complications include colonic strictures and rectovaginal fistulae. The benefits of medical therapy compared with conservative therapy are not known, as comparative clinical management trials have not been performed.

Noninfectious colitides: collagenous colitis, lymphocytic colitis, diversion colitis, and chemically induced colitis

Approximately 10% of patients with chronic diarrhea carry a diagnosis of microscopic colitis. The endoscopic appearance of both collagenous colitis and lymphocytic colitis may be normal; however, biopsies confirm the diagnosis. Available treatments include antidiarrheals, bismuth salicylate, and budesonide. Although most patients with fecal diversion may have endoscopic evidence of colitis, a much smaller percentage of patients are symptomatic. Some cases of diversion colitis respond to treatment with short-chain fatty acid enemas; however, return of the fecal stream is the most successful therapy. A variety of oral, intravenous, and per rectum chemicals may cause colitis; symptoms usually abate when chemical exposure is discontinued.

Colonic toxicity of administered drugs and chemicals

Although uncommon, medication-induced colonotoxicity is important to recognize because medication cessation generally leads to prompt clinical improvement, while medication continuation results in disease exacerbation. This review categorizes the association between medications and colonotoxicity as "well-established" or "probable," according to the following criteria: total number of reported cases, number of different research groups reporting an association, experimental and pharmacologic evidence of an association, and validity of an association in each reported case. Cocaine, ergotamine, estrogen, sodium polystyrene, alosetron, amphetamines, pseudoephedrine, and vasopressin are associated with colonic ischemia. The mechanisms include vasospasm, thrombogenesis, and shunting of blood from mesenteric vessels. Narcotics, phenothiazines, vincristine, atropine, nifedipine, and tricyclic antidepressants are associated with colonic pseudo-obstruction. The mechanisms include antagonizing prokinetic neurotransmitters, stimulating antikinetic neurotransmitters, promoting dysmotility, relaxing smooth muscle, and injuring enteric neurons. Numerous antibiotics are associated with pseudomembranous colitis; ampicillin is associated with hemorrhagic colitis; chemotherapy is associated with neutropenic colitis; and deferoxamine is associated with Yersinia enterocolitis. Mechanisms of these toxicities include altering normal bowel flora, weakening immunologic defenses, promoting microorganism virulence, and mucosal injury. Gold compounds, nonsteroidal antiinflammatory drugs, alpha-methyldopa, salicylates, and sulfasalazine are associated with an inflammatory or cytotoxic colitis. The mechanisms include direct mucosal cytotoxicity, antimetabolite effects, or drug allergy. Nonsteroidal antiinflammatory drugs, cyclo 3 fort, flutamide, lansoprazole, and ticlopidine are associated with lymphocytic colitis. The mechanisms include immunologic activation or attenuated immunologic defenses. Chronic cathartic use leads to colonic hypomotility and abdominal distention. Intrarectally administered corrosive compounds can produce a toxic colitis.

Toxicity of ingested formalin and its management

Formaldehyde is a physiological intermediary metabolite taking part in many biological process in the body. It is a constituent of many items of daily use, including foods. It is also used in medicine for treatment of some conditions. A 40% solution of formaldehyde in water is known as formalin. Formalin is irritating, corrosive and toxic and absorbed from all surfaces of the body. Ingestion is rare because of alarming odour and irritant effect but documented in accidental, homicidal or suicidal attempts. Ingestion can lead to immediate deleterious effects on almost all systems of the body including gastrointestinal tract, central nervous system, cardiovascular system and hepato-renal system, causing gastrointestinal hemorrhage, cardiovascular collapse, unconsciousness or convulsions, severe metabolic acidosis and acute respiratory distress syndrome. No specific antidote is available. Treatment of toxicity is supportive care of the various organ systems. Multidisciplinary approach is required for proper management.

Acute colitis caused by caustic products

We report two cases of acute proctocolitis caused by rectal application of caustic products of domestic use. One 61-yr-old woman applied an ammonia solution enema; the other patient, a 63-yr-old woman, accidentally applied an enema containing lye. Both patients presented with intense anal pain, but the first patient also had abdominal pain with guarding, hematochezia, and leucocytosis. An acute proctocolitis was found at sigmoidoscopy in both patients. Only conservative and symptomatic measures were prescribed in both cases, and a clinical and endoscopic recovery was seen. In spite of persistent fibrosis in the lamina propria, no signs of stenosis were found.

Paediatric enema syndrome in a rural African setting

We have observed a distinct clinical syndrome amongst acutely unwell children frequently associated with the administration of a traditional medicine enema. We describe the clinicopathological features of this 'enema syndrome' based on retrospective case note review of 50 consecutive admissions to a South African rural district hospital. Admission was frequently prompted by sudden, marked clinical deterioration following enema administration (68% seen within 24 h). Respiratory distress with tachypnoea, abdominal distension, hypotonia and loss of consciousness occurred frequently. In-hospital mortality was 28% and was higher in those receiving herbal (43%) rather than chemical (21%) enemas. Hyperkalaemia, leucocytosis (> 15,000 mm3) and respiratory distress occurred more frequently in those who died. Diagnosis of an underlying illness was established in 78%. Whilst the majority of enemas are given without incident, children struggling with an underlying illness may be unable to tolerate rectally administered traditional medicines. Toxic chemical substances in frequent use may increase complication rates.

Endoscope-induced colitis: description, probable cause by glutaraldehyde, and prevention

Six cases of acute, self-limited colitis that occurred after screening flexible sigmoidoscopy were deduced to be iatrogenic, probably caused by glutaraldehyde residues in the endoscopes after disinfection in an automatic disinfecting machine. The concentration of these residues was indirectly estimated by conductivity measurements of electrolyte concentration in the rinse-water tank of the disinfecting machine during and after five cycles and also in fluid remaining on the surface of the endoscopes and in the endoscope channels. After five cycles, residues in both the rinse water and fluid in the endoscope channels contained the equivalent of 0.2% glutaraldehyde. This was the result of a combination of technical and human errors. It can be prevented by changing the rinse water after each cycle, using forced air to dry the instruments, and washing the endoscopes before use. Users of the automatic disinfecting machine should be aware of the potential accumulation of toxic levels of residues that remain in endoscopes after disinfection.