LAUSR

A 72-year-old male with medical history of smoking and arterial hypertension, had rectal adenocarcinoma in 2008; he was treated with neoadjuvant chemoradiotherapy and low anterior resection with a temporary loop ileostomy. After ileostomy closure, the patient did not present functional digestive problems until 6 years later approximately, when he started to complain of constipation, progressively more severe, needing to get into a prone position in order to press on his abdomen to achieve the pass of gases. In several urgent consultations for abdominal swelling during the last 3 years, small bowel obstruction was never demonstrated, while colonic distension without occlusive cause was constantly observed at radiological examinations. The pseudo-obstruction was always resolved with phosphate or water enemas and laxatives. No local or distant recurrence was observed in follow-up and colonoscopy ruled out anastomotic stenosis. With the aim of preventing further crises of pseudo-obstruction and improving his quality of life, it was decided to palliate the colonic dysfunction using transanal irrigation (TAI) therapy with the Peristeen system (Coloplast A/S, Humlebaek, Denmark). A specialist nurse taught and supervised the patient during the first 3 months. Over the last 2 years, the patient was performing two irrigations per week and he reached a good control of symptoms. In March 2021, he consulted the emergency department for abdominal distension and pain started 4 days before, associated with vomiting and absence of bowel movements. The patient reported that he had self-administered TAI unsuccessfully, so he performed two more irrigations on the same day (3 L of water in total), but still without stool evacuation. Blood test showed elevated C-reactive protein (319 mg/L), leucocytosis (14.1 10E9/ L) and minimal lactate elevation (2.47 mmol/L); abdominal X-ray was suggestive of important colon dilatation. Nasogastric and rectal tube were placed but, in a few hours, the patient presented clinical worsening with hypotension and cardiorespiratory arrest, promptly recovered. Abdominal tomography showed severe distension of the entire colon without signs of perforation or intestinal distress (Fig. 1). Consequently, a decompressive colonoscopy was performed describing great colonic distention with abundant faecal liquid that was aspirated showing diffuse mucosal erythema and greyish mucosa with patchy areas of necrosis in the left colon. Urgent laparotomy was indicated finding significant dilatation with ischemia of the entire colic frame (Fig. 2). Total colectomy (including previous colorectal anastomosis) with end ileostomy was performed. After 24 h in the intensive care unit, the patient was improving and was discharged 2 weeks after surgery. The histopathological diagnosis of the resected colon confirmed the macroscopic intraoperative finding, reporting: ‘chronic pancolitis with crypt atrophy and regenerative epithelial changes; ischemic changes with luminal dilation and intestinal perforation; one end of the surgical specimen shows ischemic necrosis; negative immunohistochemical staining for Cytomegalovirus; absence of structural changes of crypts, typical of inflammatory bowel disease and doubtful immunohistochemical positivity for Spitochetes’. No histological data were reported regarding possible infection due to Clostridium difficile. The syphilis infection was ruled out by postoperative serological test. TAI has been gaining acceptance as a treatment option for different bowel dysfunctions such as neurogenic disorders, chronic constipation,