INTRODUCTION: Indwelling catheter fecal diversion systems such as the Zassi Bowel Management System are commonly used in intensive care units in patients with diarrhea or fecal incontinence. The ability to contain and divert stool can be challenging and is important in the prevention of infection and skin breakdown as well as reducing nursing burden. The system is composed of a tension cuff, which resides in the rectal vault, and a drainage system. The system is largely reported as safe and the use of the device is increasing. The manufacturer states that the device can be used up to twenty nine days and lists infection, obstruction, perforation, pressure necrosis, fecal leakage, and loss of sphincter tone as possible complications of the device. Mucosal pressure necrosis and ulceration are known risks of the device, however, reported cases are rare. Since using the device at our institution, we have seen three cases of rectal bleeding that appears to be related to the devise. The complication of pressure necrosis may be under reported and warrant further study. This report is of severe life-threatening bleeding due to the Zassi Bowel Management System.
CASE PRESENTATION: A sixty year old man with multiple medical problems presented to the intensive care unit with sepsis and respiratory failure. The patient had a report of a normal colonoscopy approximately one month prior to his hospital admission. He was resuscited, treated with antibiotics, and weaning from the ventilator. After several days in the intensive care unit he developed significant diarrhea. Multiple stool studies were negative for infection and a Zassi Bowel Management System was placed. After seven days with the system in place he developed acute hematochezia to the point that he was transfused packed red blood cells. A colonoscopy was performed and the patient was found to have significant amount of active bleeding. He had two large ulcerations covering one third of the circumference jut proximal to the anorectal verge and one visible bleeding vessel. Multiple epinephrine injections, haemostatic clipping and use of argon plasma coagulator (ACP) were required to control bleeding. A full colonoscopy and upper endoscopy revealed no other source of bleeding. The patient required a total of nine units of packed red blood cells. Once homeostasis was achieved the rest of his ICU stay was unremarkable.
DISCUSSIONS: We report a case in which a patient with an indwelling catheter fecal diversion system developed severe clinically significant rectal ulceration and bleeding seven days after placement of the device. This is a rare complication of the system that may be under-reported.
CONCLUSION: •We report a case of life-threatening rectal bleeding due to pressure necrosis from an indwelling catheter fecal diversion system. Two less severe cases have been reported at our institution.•Although few reports of this complication are in the literature, the risk is real and may be underreported.•Further studies to determine which patients are at increased risk of developing this complication are warranted.
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