A Rare Case of Perineal Pain: Intestinal Perforation Caused by a Press-Through Package Shigehito Sato, MD, Takuo Endo,
MD,
Keiichi Tajima,
MD,
and Yoshihiro Sanada, MD
Divisions of Anesthesiology and Surgery, Tsuchiura Kyodo Hospital, Tsuchiura-City,Japan
P
atients with advanced rectal cancer sometimes complain of perineal or pelvic pain, or both (1,2). One patient who had undergone surgery for rectal cancer 10 yr earlier visited our pain clinic complaining of perineal pain. We assumed that the pain was due to a local invasion of recurrent cancer, and caudal blocks were performed. A laparotomy was performed because a vesicointestinal fistula was suspected during the pain management. A pressthrough package (PTP) was found within a mass of abscess in the pelvic cavity, with one portion of the intestine perforated. After the laparotomy, the patient was discharged and was pain free. A case of fatal fecal peritonitis resulting from colon perforation caused by plastic sheeting has been reported (3). We present a rare case of perineal pain caused by intestinal perforation that had occurred 12 mo earlier after the accidental ingestion of a PTP.
Case Report A 50-yr-old woman of normal intelligence who had undergone a low anterior resection with end-to-end anastomosis for rectal cancer 10 yr before complained of sudden lower abdominal pain. She had also had an uneventful cholecystectomy for acute cholecystitis 3 mo earlier. The patient underwent many examinations without detection of abnormal findings, and after treatment with oral analgesics, the abdominal pain decreased gradually, except for persistent perineal pain. Because the pain was continuous and unresponsive to analgesics, we suspected that it was due to local recurrence of the patient’s rectal cancer, although there was no evidence to support this. The patient reported to our pain clinic 11 mo after the appearance of the sudden lower abdominal pain. Because she complained of perineal pain only, a Accepted for publication April 20, 1992. Address correspondence to Dr. Sato, Department of Anesthesiology, Institute of Clinical Medicine, University of Tsukuba, Tsukuba-shi, Ibaraki 305, Japan.
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Anesth Analg 1992;75:45&7
caudal block with 10 mL of 0.25% bupivacaine was performed. She complained of feeling pressure at the caudal region during the injection of anesthetics. Moreover, the pain did not disappear after the block. Caudal blocks were performed five times every other day with no improvement over the first block. With the sixth caudal block, we aspirated purulent discharge through a block needle. We administered antibiotics locally and orally, suspecting that the infection was caused by our needle. Two days later, her urine was a muddy yellow and smelled of stool. The patient was referred to the surgery department because of a suspected vesicointestinal fistula. After detailed examinations by urologists, gynecologists, and surgeons, a laparotomy was performed because a recurrence of rectal cancer was suspected. During the procedures for detaching the adhered intestines, a purulent discharge appeared from a space between the urinary bladder and uterus. The abscess occupied a space created by the cystic bladder as the frontal wall, the uterus as the posterior wall, and a lump of adhered small intestines as the upper wall. After the abscess was drained, a PTP containing an intact tablet was found (Figure l),and a perforated portion of small intestine was confirmed. Anastomosis between the small intestines was performed; however, the vesical fistula did not need a surgical closure. The patient’s complaints disappeared postoperatively, and she was discharged 2 wk after the operation. She could not remember when she took the tablet embedded in the PTP, but she mentioned that she might have taken it along with other drugs in the darkness of a bedroom at night several weeks before the sudden onset of the abdominal pain.
Discussion Intestinal obstruction resulting from ingested foreign objects is common, but perforation is rare (4). Button battery ingestion in infants and children has been reported, but these objects are usually safe (5). Surgical sponges retained postoperatively do not cause a 01992 by the International Anesthesia Research Society 0003-2999/!121$5.00
CASE REPORTS
ANESTH ANALG 1992;75:45&7
Figure 1. (A) A press-through package with an intact tablet found in an intestinal abscess. (B) An identical, new tablet embedded in a PTP.
significant problem, except in rare cases of related abscess (6,7). Considering the type of operation previously performed in this patient for rectal cancer, there would be no cause-effect relation between the operation and colon perforation. Severe cases of intestinal perforation resulting from ingested fish bones (8) and a chicken bone (4) have been reported. In the latter case, an ingested chicken bone perforated the colon. Only one fatal case of intestinal perforation after ingestion of plastic sheeting from a PTP has been reported (3). This case, involving a mentally retarded patient, showed severe fecal peritonitis, and a PTP was found by autopsy. A PTP consists of a dome of vinyl chloride and a thin aluminum lid. Because this container is very easy to separate and carry, many drugs are packaged in this way; however, after a PTP is separated, each corner has sharp edges. If ingested accidentally, it becomes a dangerous foreign body. Moreover, PTPs are unfortunately radiolucent, so their presence cannot be confirmed by radiographic examination. A nondiagnosed radiolucent plastic coin that remained impacted for 11 mo in the esophageal wall of a child was reported (9). In our patient, approximately 12 mo passed before the PTP was discovered. We believe that the internal pressure in the patient’s abscess was high and that the purulent discharge flowed out from the closed space of the abscess during laparotomy. Moreover, a vesical fis-
457
tula between the abscess occurred 2 days after aspiration of the purulent discharge. When the purulent discharge was aspirated from the caudal space, we thought that the infection was caused by the caudal blocks. Because the caudal space was anatomically close to the intraabdominal abscess, we believed that the infection in the caudal space was due to spread from the abdominal abscess through coarse tissues within the sacral foramina. The complaint by the patient of pressure during caudal block may also support this possibility. In summary, we present a rare case of perineal pain caused by ingestion of a PTP. Ingestions of PTPs are almost always due to patient carelessness, although a case of mental retardation has been reported (3). In our pain clinic, we sometimes prescribe drugs for episodes of pain. It is therefore possible that the accidental ingestion of a PTP may occur because of impatience experienced by the patient during severe pain. In our medical practice, we need to ensure that there is sufficient workup before the treatment of chronic pain, and if repeated blocks are unsuccessful, another etiology, such as ingestion of a radiolucent foreign body, should be suspected as a possible cause of chronic perineal pain.
References 1. Patt R, Jain S. Long term management of a patient with perineal pain secondary to rectal cancer. J Pain Symptom Manag 1990; 5:12743. 2. Longo WE, Ballantyne GH, Bilchik AJ. Advanced rectal cancer. What is the best palliation. Dis Colon Rectum 1988;31:842-7. 3. Fernando GCA. Colonic perforation following ingestion of plastic sheeting. Med Sci Law 1989;29:263-4. 4. Osler T, Stackhouse CL, Dietz PA, Guiney WB. Perforation of the colon by ingested chicken bone, leading to diagnosis of carcinoma of the sigmoid. Dis Colon Rectum 1985;28:177-9. 5. Kost Kh4, Shapiro RS. Button battery ingestion: a case report and review of the literature. J Otolaryngol 1987;16:252-7. 6. Richards WO, Keramati 8, Scovill WA. Fate of retained foreign bodies in the peritoneal cavity. South Med J 1986;79:496-8. 7. Drucker EA, Deiuca SA. Retained surgical sponges. Intraabdominal abscesses. Am Fam Physician 1984;30:125-6. 8. Ichimiya I, Fujiyoshi T, Kurono Y, Mogi G. Multiple foreign bodies (fish bones) in the esophagus and rectum. Auris Nasus Larynx 1988;15:51-55. 9. Fernandes ET, Hollabaugh RS, Boulden T. Mediastinal mass and radiolucent foreign body. J Pediatr Surg 1989;24:1135-6.
MD,
Keiichi Tajima,
MD,
and Yoshihiro Sanada, MD
Divisions of Anesthesiology and Surgery, Tsuchiura Kyodo Hospital, Tsuchiura-City,Japan
P
atients with advanced rectal cancer sometimes complain of perineal or pelvic pain, or both (1,2). One patient who had undergone surgery for rectal cancer 10 yr earlier visited our pain clinic complaining of perineal pain. We assumed that the pain was due to a local invasion of recurrent cancer, and caudal blocks were performed. A laparotomy was performed because a vesicointestinal fistula was suspected during the pain management. A pressthrough package (PTP) was found within a mass of abscess in the pelvic cavity, with one portion of the intestine perforated. After the laparotomy, the patient was discharged and was pain free. A case of fatal fecal peritonitis resulting from colon perforation caused by plastic sheeting has been reported (3). We present a rare case of perineal pain caused by intestinal perforation that had occurred 12 mo earlier after the accidental ingestion of a PTP.
Case Report A 50-yr-old woman of normal intelligence who had undergone a low anterior resection with end-to-end anastomosis for rectal cancer 10 yr before complained of sudden lower abdominal pain. She had also had an uneventful cholecystectomy for acute cholecystitis 3 mo earlier. The patient underwent many examinations without detection of abnormal findings, and after treatment with oral analgesics, the abdominal pain decreased gradually, except for persistent perineal pain. Because the pain was continuous and unresponsive to analgesics, we suspected that it was due to local recurrence of the patient’s rectal cancer, although there was no evidence to support this. The patient reported to our pain clinic 11 mo after the appearance of the sudden lower abdominal pain. Because she complained of perineal pain only, a Accepted for publication April 20, 1992. Address correspondence to Dr. Sato, Department of Anesthesiology, Institute of Clinical Medicine, University of Tsukuba, Tsukuba-shi, Ibaraki 305, Japan.
456
Anesth Analg 1992;75:45&7
caudal block with 10 mL of 0.25% bupivacaine was performed. She complained of feeling pressure at the caudal region during the injection of anesthetics. Moreover, the pain did not disappear after the block. Caudal blocks were performed five times every other day with no improvement over the first block. With the sixth caudal block, we aspirated purulent discharge through a block needle. We administered antibiotics locally and orally, suspecting that the infection was caused by our needle. Two days later, her urine was a muddy yellow and smelled of stool. The patient was referred to the surgery department because of a suspected vesicointestinal fistula. After detailed examinations by urologists, gynecologists, and surgeons, a laparotomy was performed because a recurrence of rectal cancer was suspected. During the procedures for detaching the adhered intestines, a purulent discharge appeared from a space between the urinary bladder and uterus. The abscess occupied a space created by the cystic bladder as the frontal wall, the uterus as the posterior wall, and a lump of adhered small intestines as the upper wall. After the abscess was drained, a PTP containing an intact tablet was found (Figure l),and a perforated portion of small intestine was confirmed. Anastomosis between the small intestines was performed; however, the vesical fistula did not need a surgical closure. The patient’s complaints disappeared postoperatively, and she was discharged 2 wk after the operation. She could not remember when she took the tablet embedded in the PTP, but she mentioned that she might have taken it along with other drugs in the darkness of a bedroom at night several weeks before the sudden onset of the abdominal pain.
Discussion Intestinal obstruction resulting from ingested foreign objects is common, but perforation is rare (4). Button battery ingestion in infants and children has been reported, but these objects are usually safe (5). Surgical sponges retained postoperatively do not cause a 01992 by the International Anesthesia Research Society 0003-2999/!121$5.00
CASE REPORTS
ANESTH ANALG 1992;75:45&7
Figure 1. (A) A press-through package with an intact tablet found in an intestinal abscess. (B) An identical, new tablet embedded in a PTP.
significant problem, except in rare cases of related abscess (6,7). Considering the type of operation previously performed in this patient for rectal cancer, there would be no cause-effect relation between the operation and colon perforation. Severe cases of intestinal perforation resulting from ingested fish bones (8) and a chicken bone (4) have been reported. In the latter case, an ingested chicken bone perforated the colon. Only one fatal case of intestinal perforation after ingestion of plastic sheeting from a PTP has been reported (3). This case, involving a mentally retarded patient, showed severe fecal peritonitis, and a PTP was found by autopsy. A PTP consists of a dome of vinyl chloride and a thin aluminum lid. Because this container is very easy to separate and carry, many drugs are packaged in this way; however, after a PTP is separated, each corner has sharp edges. If ingested accidentally, it becomes a dangerous foreign body. Moreover, PTPs are unfortunately radiolucent, so their presence cannot be confirmed by radiographic examination. A nondiagnosed radiolucent plastic coin that remained impacted for 11 mo in the esophageal wall of a child was reported (9). In our patient, approximately 12 mo passed before the PTP was discovered. We believe that the internal pressure in the patient’s abscess was high and that the purulent discharge flowed out from the closed space of the abscess during laparotomy. Moreover, a vesical fis-
457
tula between the abscess occurred 2 days after aspiration of the purulent discharge. When the purulent discharge was aspirated from the caudal space, we thought that the infection was caused by the caudal blocks. Because the caudal space was anatomically close to the intraabdominal abscess, we believed that the infection in the caudal space was due to spread from the abdominal abscess through coarse tissues within the sacral foramina. The complaint by the patient of pressure during caudal block may also support this possibility. In summary, we present a rare case of perineal pain caused by ingestion of a PTP. Ingestions of PTPs are almost always due to patient carelessness, although a case of mental retardation has been reported (3). In our pain clinic, we sometimes prescribe drugs for episodes of pain. It is therefore possible that the accidental ingestion of a PTP may occur because of impatience experienced by the patient during severe pain. In our medical practice, we need to ensure that there is sufficient workup before the treatment of chronic pain, and if repeated blocks are unsuccessful, another etiology, such as ingestion of a radiolucent foreign body, should be suspected as a possible cause of chronic perineal pain.
References 1. Patt R, Jain S. Long term management of a patient with perineal pain secondary to rectal cancer. J Pain Symptom Manag 1990; 5:12743. 2. Longo WE, Ballantyne GH, Bilchik AJ. Advanced rectal cancer. What is the best palliation. Dis Colon Rectum 1988;31:842-7. 3. Fernando GCA. Colonic perforation following ingestion of plastic sheeting. Med Sci Law 1989;29:263-4. 4. Osler T, Stackhouse CL, Dietz PA, Guiney WB. Perforation of the colon by ingested chicken bone, leading to diagnosis of carcinoma of the sigmoid. Dis Colon Rectum 1985;28:177-9. 5. Kost Kh4, Shapiro RS. Button battery ingestion: a case report and review of the literature. J Otolaryngol 1987;16:252-7. 6. Richards WO, Keramati 8, Scovill WA. Fate of retained foreign bodies in the peritoneal cavity. South Med J 1986;79:496-8. 7. Drucker EA, Deiuca SA. Retained surgical sponges. Intraabdominal abscesses. Am Fam Physician 1984;30:125-6. 8. Ichimiya I, Fujiyoshi T, Kurono Y, Mogi G. Multiple foreign bodies (fish bones) in the esophagus and rectum. Auris Nasus Larynx 1988;15:51-55. 9. Fernandes ET, Hollabaugh RS, Boulden T. Mediastinal mass and radiolucent foreign body. J Pediatr Surg 1989;24:1135-6.
