Enema-induced rectal injury presenting as upper gastrointestinal bleeding: a case report
This case report describes a rare instance where improper administration of a glycerin enema by family members caused a rectal mucosal injury that presented deceptively as upper gastrointestinal bleeding in a postoperative craniotomy patient, ultimately diagnosed and treated via endoscopy.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
The Mystery of the "Wrong" Bleeding
Imagine a 61-year-old man who recently had brain surgery to fix a bleed inside his skull. Ten days later, he starts vomiting something that looks like wet coffee grounds and passes black, tarry stool.
In the medical world, these two symptoms are like flashing red sirens that usually point to a problem in the upper stomach (like a bleeding ulcer). It's the classic "Upper GI Bleed" alarm.
The First Detour:
Doctors at the first hospital saw the "coffee grounds" and the black stool. They assumed the problem was high up in the digestive tract. They sent a tiny camera down his throat (a gastroscopy) to find the leak. But the camera came back empty-handed—there was no bleeding source in the stomach or esophagus. The map was wrong.
The Plot Twist:
The patient was moved to a new hospital. Because the stomach camera found nothing, the doctors decided to look deeper. They used a special CT scan (like a high-tech X-ray that shows moving blood) and discovered the real culprit: Active bleeding in the rectum, which is at the very bottom of the digestive system.
They then used a camera to look at the rectum and found a small, shallow cut about 4 to 6 centimeters inside. They fixed it with tiny metal clips, like using a stapler to close a small tear in a piece of paper.
The "Aha!" Moment:
Once the bleeding stopped, the doctors asked the family for more details. The family finally admitted: "Oh, right, we gave him a glycerin enema (a liquid squirt to help with constipation) just before he started vomiting."
It turned out the enema had accidentally scratched the lining of the rectum. This scratch was the source of the bleeding.
Why Was It So Confusing? (The "Traffic Jam" Analogy)
You might be asking: "If the bleed was at the bottom (the rectum), why did he vomit coffee grounds (which usually means a top bleed)?"
Think of the digestive system as a long highway.
- Normal Traffic: If you have a spill at the bottom of the highway (the rectum), the cars (blood) usually just exit the bottom. You see fresh red blood.
- This Patient's Traffic: This patient had just had brain surgery and was in a coma-like state. His body's "traffic control system" (the nerves that move food and waste) was completely broken. The highway was gridlocked.
Because the traffic was stuck, the blood from the rectal scratch didn't exit immediately. Instead, it got stuck in the "tunnels" of the intestine for a long time.
- The Coffee Grounds: As the blood sat there, it got mixed with stomach acid (even though the leak wasn't in the stomach). This acid turned the blood dark and granular, looking exactly like coffee grounds.
- The Black Stool: The blood sat long enough to turn black and tarry as it moved through the system.
So, the "traffic jam" caused the blood to look like it came from the top, even though the leak was at the bottom. It was a case of mistaken identity caused by a traffic jam.
The Big Lesson
The main takeaway from this story isn't that rectal bleeding always looks like stomach bleeding. It's that in patients with severe brain injuries, the usual rules don't always apply.
- The Trap: Doctors saw the "coffee grounds" and immediately assumed the problem was high up. They didn't think to ask about the enema because the patient couldn't speak, and the family didn't mention it until later.
- The Fix: The doctors had to trust the "traffic cameras" (the CT scan) over the "symptoms" (the vomit). When the symptoms and the scan didn't match, the scan won.
In short: Sometimes, a scratch at the very end of the road can look like a crash at the beginning, especially when the body's internal traffic lights are broken. Doctors need to be careful not to jump to conclusions based on symptoms alone, especially when the patient can't tell their own story.
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