Enema Administration in the Setting of Multiple Hematomas
Do not administer an enema to this patient given the presence of multiple expanding retroperitoneal and abdominal wall hematomas, particularly with documented interval increase in size. 1, 2
Critical Safety Concerns
The imaging findings reveal several absolute contraindications to enema administration:
Active bleeding with expanding hematomas: The CT demonstrates interval increase in the right retroperitoneal hematoma and iliacus muscular hematoma, plus new left inguinal and left retroperitoneal hematomas. This indicates ongoing or recent bleeding that has not been fully controlled despite embolization procedures. 1
Likely coagulopathy: The presence of multiple hematomas post-embolization strongly suggests an underlying coagulation disorder or therapeutic anticoagulation. Enema administration in anticoagulated patients carries significant risk of rectal perforation and intramural hematoma formation. 1, 2
Mechanical bowel displacement: The large right retroperitoneal hematoma is causing mass effect and displacement of the ascending colon and pelvic contents. This anatomical distortion increases the risk of perforation during enema tip insertion or balloon inflation. 3, 2
Specific Risks in This Clinical Context
Perforation risk is substantially elevated in this patient for multiple reasons:
Enema-related perforations occur in 0.02-0.04% of patients under normal circumstances, but risk increases dramatically with anatomical distortion, elderly patients, and compromised tissue integrity. 3, 2
Rectal trauma from enema tips or retention balloons is the most common traumatic cause of perforation, and this patient's displaced pelvic anatomy makes proper positioning extremely difficult. 3
Patients on anticoagulation who receive enemas have documented cases of severe rectal and colonic mural hematomas requiring surgical intervention. 1
Perforation in the setting of existing hematomas and likely coagulopathy would be catastrophic, potentially causing intraperitoneal contamination, severe sepsis, and shock. 3, 2
Alternative Management for Stool Burden
The moderate stool burden should be managed medically without mechanical intervention:
Initiate oral or nasogastric water-soluble contrast agents (50-150 mL) if the patient can tolerate oral intake and there is no evidence of complete obstruction. This approach is safe and therapeutic for constipation management. 4
Implement bowel rest, adequate hydration with IV crystalloids, and electrolyte correction as supportive measures. 4, 5
Consider gentle oral laxatives (polyethylene glycol-based solutions) once hemodynamic stability is confirmed and hematoma expansion has ceased. 4
The CT explicitly states "no evidence of large bowel obstruction," which means the stool burden is not causing mechanical obstruction and does not require urgent intervention. 5
Monitoring Requirements
Before any bowel intervention, the following must be addressed:
Stabilization of all hematomas with no further expansion on repeat imaging. 1, 6
Correction of any coagulopathy (INR, platelet count, anticoagulation status). 1, 6
Hemodynamic stability without ongoing transfusion requirements. 6
Surgical consultation given the complex post-embolization state and multiple hematomas. 1, 2
Clinical Pitfall to Avoid
The most dangerous error would be focusing solely on the "moderate stool burden" finding while ignoring the life-threatening hematoma complications. The stool burden is an incidental finding that poses no immediate threat, whereas enema administration could precipitate catastrophic bleeding or perforation in this unstable patient. 3, 1, 2