FATAL COMPLICATION OF RECTAL WASHING: A CASE REPORT OF HYPOKALEMIA AND CARDIAC ARREST IN ADVANCED RECTOSIGMOID CANCER
Universitas Udayana
Central General Hospital Prof. Dr. I.G.N.G Ngoerah Denpasar, Bali
Introduction. Rectal washing is a routine procedure in bowel preparation but may cause complications, especially in high-risk patients. This report discusses a case of fatal complications following rectal washing in a patient with a malignant rectosigmoid tumor and comorbidities, emphasizing the potential risks of hypokalemia and cardiac instability. Method. A case study was conducted on a 65-year-old male with chronic heart failure and suspected rectosigmoid malignancy, who underwent colonoscopy at Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali. Comprehensive clinical data were obtained, including detailed medical history, physical examination, laboratory testing, imaging studies (ultrasound and CT scan), and colonoscopy with biopsy. Management adhered to established protocols for atrial fibrillation with rapid ventricular response, chronic heart failure, partial bowel obstruction, and suspected metastatic rectosigmoid carcinoma. The patient's condition was closely monitored through continuous assessment of vital signs, clinical progression, and follow-up diagnostics. Result & Analysis. The case highlights the interplay of rectal washing, electrolyte imbalance (suspected hypokalemia), and cardiac arrhythmia in a high-risk patient. Contributing factors such as metastatic burden and comorbidities compounded the fatal outcome. Discussion. This case underscores the need for vigilant monitoring and tailored bowel preparation strategies in patients with significant comorbidities to mitigate life-threatening complications.
Keywords: Bowel Preparation Complication Rectal Washing Electrolyte Imbalance Case Series
Dolkar, T. et al. (2022) 'Persistent hypokalemia in a patient with Ogilvie’s syndrome,' Cureus [Preprint]. https://doi.org/10.7759/cureus.32056.
Khan, S. and Khan, S.U. (2020) 'Adverse drug event of hypokalaemia‐induced cardiotoxicity secondary to the use of laxatives: A systematic review of case reports,' Journal of Clinical Pharmacy and Therapeutics, 45(5), pp. 927–936. https://doi.org/10.1111/jcpt.13204.
Farah, R. (2005) Fatal acute sodium phosphate enemas intoxication, Acta Gastro-Enterologica Belgica, pp. 392–393. https://www.ageb.be/Articles/Volume%2068%20%282005%29/Fasc3/20-farah.pdf.
Bennett, A. and Stryjewski, G. (2006) 'Severe hypokalemia caused by oral and rectal administration of bentonite in a pediatric patient,' Pediatric Emergency Care, 22(7), pp. 500–502. https://doi.org/10.1097/01.pec.0000227873.05119.e6.
Sánchez, M.J.N., Swaneck, S.L. and Díaz, F. (2017) 'Severe tetany due to phosphate enemas use, case report,' Revista Chilena De Pediatría, 88(3), pp. 383–387. https://doi.org/10.4067/s0370-41062017000300011.
Dunning, M.F. and Plum, F. (1956) 'Potassium depletion by enemas,' The American Journal of Medicine, 20(5), pp. 789–792. https://doi.org/10.1016/0002-9343(56)90161-9.
Flentie, E.H. and Cherkin, A. (1958) 'Electrolyte effects of the sodium phosphate enema,' Diseases of the Colon & Rectum, 1(4), pp. 295–299. https://doi.org/10.1007/bf02617066.
Martin, R.R. (1987) 'Fatal poisoning from sodium phosphate enema,' JAMA, 257(16), p. 2190. https://doi.org/10.1001/jama.1987.03390160076030.
Rectal cancer treatment (2024). https://www.cancer.gov/types/colorectal/patient/rectal-treatment-pdq.
Rectal cancer - Diagnosis and treatment - Mayo Clinic (no date). https://www.mayoclinic.org/diseases-conditions/rectal-cancer/diagnosis-treatment/drc-20352889.
Ori, Y. (2012) 'Fatalities and severe metabolic disorders associated with the use of sodium phosphate enemas,' Archives of Internal Medicine, 172(3), p. 263. https://doi.org/10.1001/archinternmed.2011.694.
Esmo Rectal Cancer: ESMO Clinical Practice Guidelines. https://www.esmo.org/guidelines/guidelines-by-topic/esmo-clinical-practice-guidelines-gastrointestinal-cancers/rectal-cancer.
Lee, S., Kwon, J. and Lee, J. (2020) 'Rectal perforations caused by cleansing enemas in chronically constipated patients: Two case reports,' SAGE Open Medical Case Reports, 8. https://doi.org/10.1177/2050313x20938251.
FDA. FDA Warning on Sodium Phosphate Enemas: Serious Harm from Exceeding Recommended Dose. Published January 8, 2023. Accessed January 16, 2025. https://www.fda.gov/media/87428/download
Reumkens, A. et al. (2022) 'Electrolyte disturbances after bowel preparation for colonoscopy: Systematic review and meta‐analysis,' Digestive Endoscopy, 34(5), pp. 913–926. https://doi.org/10.1111/den.14237.
Zhao, Y. and Dong, H.-S. (2023) 'Hyponatremic encephalopathy due to polyethylene glycol-based bowel preparation for colonoscopy: A case report,' World Journal of Clinical Cases, 11(1), pp. 187–192. https://doi.org/10.12998/wjcc.v11.i1.187.
Moseley, P.K. (1968) 'Fluid and serum electrolyte disturbances as a complication of enemas in Hirschsprung’s disease,' Archives of Pediatrics and Adolescent Medicine, 115(6), p. 714. https://doi.org/10.1001/archpedi.1968.02100010716013.
