What does bowel movement from a Hartman (Hartmann) pouch indicate?

Bowel Movement from Hartmann Pouch: Clinical Significance

Bowel movement or discharge from a Hartmann pouch is abnormal and indicates a serious complication requiring immediate investigation, most commonly representing a leak from the rectal stump, fistula formation (particularly ileorectostomy), or rarely, diversion colitis with mucous discharge.

Immediate Clinical Assessment

When a patient reports bowel movements or discharge from a Hartmann pouch, you must urgently assess for:

• Fever, tachycardia, hypotension, or altered mental status suggesting sepsis from rectal stump leak 1, 2
• Abdominal tenderness, distention, or peritoneal signs indicating intra-abdominal infection 1
• Character of discharge: feculent material suggests fistula formation (most commonly ileorectostomy), while mucous discharge may indicate severe diversion colitis 3, 4

Diagnostic Workup

Laboratory Studies

• Obtain blood cultures immediately if fever is present 1, 2
• Monitor C-reactive protein (CRP) as an inflammatory marker 1
• Complete blood count to assess for leukocytosis 1

Imaging

• CT scan of abdomen/pelvis is mandatory if there is concern for intra-abdominal abscess or rectal stump leak 1, 2
• Contrast study of the Hartmann pouch should be performed with water-soluble contrast medium (not barium) to detect leaks or fistulas, as clinically silent leaks can occur even 3 months or more after pouch creation 5

Common Pathologic Findings

The defunctionalized Hartmann pouch has high potential for pathologic lesions:

Acute Complications

• Rectal stump leak: Occurs more commonly than previously suspected and may be clinically silent 6, 5
• Fistula formation: "Spontaneous ileorectostomy" can develop when a leaking pouch communicates with small bowel 6
• Intra-abdominal abscess: Requires drainage if >3-6 cm, antibiotics alone may suffice for smaller collections 1

Chronic Complications (if pouch left long-term)

• Diversion colitis: Found in every pouch examined endoscopically, ranging from mild to severe 3, 4
• Neoplasm formation: Carcinoma found in 7 of 45 patients (16%) in one series, polyps in additional patients 4
• Ulceration and bleeding 7, 4

Management Algorithm

If Feculent Discharge Present

1. Obtain urgent CT imaging to identify fistula tract 5
2. Initiate broad-spectrum antibiotics targeting gram-negative bacilli and anaerobes (meropenem 1g q6h by extended infusion, or alternatives) 2
3. Surgical consultation for operative repair - non-operative attempts to seal ileorectostomy typically fail 6

If Rectal Stump Leak Confirmed

• Small abscesses (<3-6 cm): Antibiotics alone may be sufficient 1
• Larger abscesses (>3-6 cm): Percutaneous drainage plus antibiotics 1
• Sepsis/septic shock: Immediate resuscitation, urgent source control, and broad-spectrum antibiotics 1, 2
• Antibiotic duration: 4 days if adequate source control in immunocompetent patients; up to 7 days in immunocompromised or critically ill patients 2

If Mucous Discharge Only (Diversion Colitis)

• Perform proctoscopy to assess severity of inflammation 7, 4
• Severe proctitis should be treated with reanastomosis if patient is surgical candidate 4
• Regular endoscopic surveillance is mandatory given high risk of neoplasm formation 7, 4

Critical Pitfalls to Avoid

• Do not assume mucous discharge is benign: Even asymptomatic patients can harbor severe proctitis, polyps, or carcinoma in the defunctionalized pouch 4
• Do not use barium for contrast studies: Water-soluble contrast is essential to avoid complications from extravasation if leak is present 5
• Do not delay imaging in immunocompromised patients: They may have atypical presentations with less pronounced inflammatory markers despite serious infections 1, 2
• Do not forget the pouch exists: Long-term Hartmann pouches require regular follow-up with proctoscopy and contrast studies given high incidence of pathologic changes 7

Special Considerations

Immunocompromised patients (including kidney transplant recipients) warrant particularly close monitoring as they are at higher risk for severe complications and may present atypically 1, 2.