Routine Rectal Biopsy?

Profuse per rectal bleeding due to erosion of the inferior epigastric artery following a catheter tube caecostomy. Editor, We describe a case of profuse per rectal bleeding due to erosion of the right inferior epigastric artery, by a Foley catheter, used as a tube caecostomy, for decompression of underlying colonic pseudo-obstruction. Case history: A sixty-four year old male was admitted to the intensive care unit with shortness of breath secondary to left ventricular failure, and chronic obstructive airways disease. He developed gross abdominal distension, which did not settle with conservative management. Imaging showed dilated loops of large bowel. Exploratory laparotomy revealed gross dilatation of the caecum and ascending colon. No mechanical cause of obstruction was evident. A 22 gauge Foley catheter was introduced through the base of the excised appendix, after decompression of the colon with a Savage's decompressor. The Foley catheter had been introduced into the peritoneal cavity through a prior stab incision in the anterior abdominal wall, overlying the right iliac fossa. On the 9th post-operative day, the patient developed profuse fresh bleeding per rectum, associated with considerable bleeding into the caecostomy bag, from which he rapidly became shocked. Initial conservative management was abandoned in favour of a second laparotomy. Thorough examination of the colon revealed no palpable lesions. At the time of taking down the caecostomy, a copious bleed from the right inferior epigastric artery was detected, adjacent to the tract formed by the Foley catheter through the anterior abdominal wall. Following ligation of the vessel the patient's condition stabilised. No further rectal bleeding or discharge was recorded post-operatively. Discussion: The management of pseudo-obstruction 1 is often conservative. Decompression can be accomplished by the passage of a sigmoidoscope and flatus tube, or colonoscopy. Benacci et al 2 conducted a review of patients at the Mayo clinic to determine the effectiveness of catheter tube caecostomy as a means of colonic decompression. They concluded that it was expeditious and safe, with acceptable morbidity in the majority of patients. Gradual erosion of the right inferior epigastric artery by a caecostomy tube resulting in serious haemorrhage has not been previously documented. Computerised search of Medline and Pub Med databases did not reveal a single recorded case. The inferior epigastric artery 3 originates from the external iliac artery just superior to the inguinal ligament, runs superiorly in the transversalis fascia, and enters the rectus sheath below the arcuate line, lying deep to …