Outcomes of children with constipation and autism spectrum disorder treated with antegrade continence enemas.

BACKGROUND: Treatment of functional constipation (FC) in children with autism spectrum disorder (ASD) is challenging due to sensory and behavioral issues. We aimed to understand whether antegrade continence enemas (ACEs) are successful in the treatment of FC in children with ASD. METHODS: A single-institution retrospective review was performed in children diagnosed with ASD and FC who underwent appendicostomy or cecostomy placement from 2007 to 2019. Descriptive statistics regarding soiling and complications were calculated. RESULTS: There were 33 patients included, with a median age of 9.7 years at the time of ACE initiation. The average intelligence quotient was 63.6 (SD = 18.0, n = 12), the average behavioral adaptive score was 59.9 (SD = 11.1, n = 13), and the average total Child Behavioral Checklist score was 72.5 (SD = 7.1, n = 10). Soiling rates were significantly lower following ACE initiation (42.3% vs. 14.8%, p = 0.04). Behavioral issues only prevented 1 patient (3.0%) from proper ACE use. Eleven patients (36.6%) were able to transition to laxatives. There were significant improvements in patient-reported outcomes measures and quality of life. CONCLUSION: Placement of an appendicostomy or cecostomy for management of FC in children with severe ASD was successful in treating constipation and improving quality of life.

Lymphoma-related intussusception in children: diagnostic challenges and clinical characteristics.

Intussusception is a common cause of acute abdominal pain in children and the most frequent cause of intestinal obstruction in infants. Although often idiopathic, it can stem from conditions like lymphoma. This study delves into lymphoma-related intussusception in children, aiming to enhance early detection and management. A retrospective review encompassed children admitted from 2012 to 2023 with intussusception due to intestinal lymphoma. Demographic, clinical, and imaging data were meticulously extracted and analyzed. The study included 31 children in the lymphoma-related intussusception group. Contrasted with non-lymphoma-related cases, the patients of lymphoma-related intussusception were notably older (median age: 87 months vs. 18.5 months), predominantly male, and demonstrated protracted abdominal pain. Ultrasound unveiled mesenteric lymph node enlargement and distinct intra-abdominal masses; enema reduction success rates were notably diminished. Detecting lymphoma-related intussusception remains intricate. Age, prolonged symptoms, and distinctive ultrasound findings can arouse suspicion. Timely surgical intervention, based on preoperative imaging, proves pivotal for accurate diagnosis. CONCLUSION:  Swift identification of lymphoma-related intussusception, distinguished by unique clinical and ultrasound features, is imperative for timely intervention and treatment. Further research is warranted to refine diagnostic approaches. WHAT IS KNOWN: • Intussusception in pediatric patients can be caused by a wide spectrum of underlying diseases including lymphoma. • Early Identifying the exact underlying cause of intussusception is crucial for tailored therapy, however often challenging and time-consuming. WHAT IS NEW: • Lymphoma-related intussusception may present with increased abdominal fluid accumulation, intestinal obstruction, and a higher likelihood of failed reduction during enema procedures. • For high-risk children, repeated ultrasound examinations or further investigations may be necessary to confirm the diagnosis.

Iatrogenic rectal perforation due to application of topical treatment in a patient with ulcerative colitis: a rare complication.

Rectal perforations due to topical treatments (enemas or foams) are unusual complications and they have been mostly reported in the use of barium enemas or in elderly patients with constipation. Very little has been reported about perforations secondary to topical treatment in patients with ulcerative colitis. We present the case of a patient with ulcerative colitis who suffered a rectal perforation complicated with a superinfected collection after the application of topical mesalazine foam.

Long-Term Outcomes of Antegrade Continence Enemas to Treat Constipation and Fecal Incontinence in Children.

OBJECTIVES: The objective of this study is to investigate long-term outcomes of antegrade continence enema (ACE) treatment in children with constipation or fecal incontinence. METHODS: Prospective cohort study including pediatric patients with organic or functional defecation disorders who started ACE treatment. Data were collected at baseline and at follow-up (FU) from 6 weeks until 60 months. We assessed parent and patient-reported gastrointestinal health-related quality of life (HRQoL) using the Pediatric Quality of Life Inventory Gastrointestinal Symptoms Module (PedsQL-GI), gastrointestinal symptoms, adverse events, and patient satisfaction. RESULTS: Thirty-eight children were included (61% male, median age 7.7 years, interquartile range 5.5-12.2). Twenty-two children (58%) were diagnosed with functional constipation (FC), 10 (26%) with an anorectal malformation, and 6 (16%) with Hirschsprung disease. FU questionnaires were completed by 22 children (58%) at 6 months, 16 children (42%) at 12 months, 20 children (53%) at 24 months, and 10 children (26%) at 36 months. PedsQL-GI scores improved overall with a significant increase at 12- and 24-month FU for children with FC and a significant increase in parent reported PedsQL-GI score at 36-month FU for children with organic causes. Minor adverse events, such as granulation tissue, were reported in one-third of children, and 10% of children needed a surgical revision of their ACE. The majority of all parents and children reported that they would "probably" or "definitely" choose ACE again. CONCLUSION: ACE treatment is perceived positively by patients and parents and can lead to long-term improvement in gastrointestinal HRQoL in children with organic or functional defecation disorders.

Epidemiology, clinical characteristics, and treatment of children with acute intussusception: a case series.

BACKGROUND: To summarize the clinical and epidemiological characteristics of acute intussusception. METHODS: This retrospective study included pediatric patients with acute intussusception admitted to the Department of Pediatric Surgery, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, from January 2014 to December 2019. RESULTS: A total of 402 infants/children were included (301 males and 101 females) with a mean age of 2.4 ± 1.5 years (2 months to 9 years). Thirty patients (7.5%) had a history of cold food intake, diarrhea, and upper respiratory infection before disease onset. Paroxysmal abdominal pain and crying occurred in 338 patients (84.1%). Eight patients (2.0%) had the typical triad, 167 (41.5%) had vomiting, 24 (6.0%) had bloody stools, and 273 (67.9%) had palpable abdominal mass. The average intussusception depth was 4.0 ± 1.4 cm. Air enema reduction was performed in 344 cases: 335 (97.3%) were successful. Fifty-eight patients were treated with intravenous phloroglucinol (2 mg/kg), and 53 (91.4%) were successful. Sixty-five patients suffered relapses, with a relapse rate of 16.8%. CONCLUSIONS: Pediatric acute intussusception is common. There was no obvious etiology. The clinical manifestations are mostly atypical. Abdominal pain is the most common complaint. Air enema reduction is an effective treatment. The recurrence rate is high.

Delayed Repeat Contrast Enema for Treatment of Pediatric Intussusception.

INTRODUCTION: Ileocolic intussusception is a common cause of pediatric bowel obstruction. Contrast enema is successful in treating the majority of patients, and if initially unsuccessful, approximately one-third may be reduced with repeat enemas. We sought to study protocol implementation for delayed repeat enema in pediatric patients not reduced completely by an initial contrast enema. Our aims were to assess repeat enema success rates and outcome differences in preprotocol and postprotocol patients with respect to (1) intussusception recurrence, (2) surgical intervention and complication rates, and (3) length of stay. MATERIALS AND METHODS: We performed a retrospective review of treatment and clinical outcomes prior to and following protocol implementation for repeat enema for intussusception at two tertiary pediatric referral hospitals. The preprotocol period was defined from 2/2013 to 2/2016, and the postprotocol period was from 8/2016 to 11/2019. RESULTS: There were 112 patients in the preprotocol group, with 74 (66%) having successful reduction following the first enema. Of the 38 patients without successful reduction, 16 (42%) patients underwent repeat enema, and five were successful (31%). The postprotocol group included 122 patients, with 84 (69%) having successful first reduction. Of the 38 patients that failed, 25 patients (66%) underwent repeat enema, of which 13 (52%) were successful. Compared to preprotocol patients, postprotocol patients had significantly more enemas repeated and a trend toward fewer surgical interventions. CONCLUSIONS: Protocol implementation of repeat delayed enemas was significantly associated with an increased rate of repeat enemas at our institutions and reduced need for operative intervention during the index stay.

Midazolam premedication in ileocolic intussusception: a retrospective multicenter study.

Ileocolic intussusception is a common cause of bowel obstruction. When spontaneous reduction does not occur, non-operative management through enema reduction is necessary. Despite the evidence indicating that sedatives favor success in the reduction, their use is still not a common practice. To determine if midazolam (MDZ) before enema improves the rate of procedure success, we retrospectively reviewed charts of patients admitted to two Italian pediatric emergency departments. Outcome measures were the success rate of the enema, recurrence, and need for surgery. Patients were grouped according to the use of MDZ or not, before hydrostatic reduction attempt. We included 69 and 37 patients in the MDZ and non-MDZ groups, respectively. The two groups did not differ in demographics, clinical characteristics, and ultrasound findings. Intussusception reduction after the first enema attempt occurred in 75% (MDZ group) and 32.4% (non-MDZ group) of patients (P < .001); 27.9% (MDZ group) and 77.8% (non-MDZ group) of patients underwent surgery (P < .001). Among them, spontaneous reduction of intussusception during the induction of general anesthesia occurred in 31.6% and 42.9% of patients, respectively (P .43). Multivariate logistic regression analysis showed that only MDZ had a positive effect on the result of the enema (OR 7.602, 95%CI 2.669-21.652, P < .001). CONCLUSION: Procedural sedation with MDZ for enema reduction of intussusception can increase the success rate and lead to a better management of patients. WHAT IS KNOWN: • Despite the evidence of the usefulness of sedatives in the reduction of intussusception, their use is still not a common practice. WHAT IS NEW: • Midazolam during enema reduction of intussusception can increase the success rate and consequently lead to better management of patients.

Surgical treatment of recurrent intussusception induced by intestinal lymphoid hyperplasia in a child: is bowel resection always necessary? A case report.

BACKGROUND: Intussusception recurrence (IR) induced by intestinal lymphoid hyperplasia (ILH) in children is rare, and surgical treatment is the final resort if IR is refractory to medications and non-surgical interventions. To date, only a few case reports have described surgical management of ILH-induced IR in children, all involving bowel resection regardless of whether there are bowel necrosis and perforation. CASE PRESENTATION: A 2-year-old boy was transferred to our department due to IR. His main complaint was abdominal pain. Color Doppler ultrasound confirmed ileocecal intussusception while no other abnormalities were found. A final diagnosis of IR with unknown causes was made. Repeated saline enema reductions and dexamethasone failed to cure the IR. Laparotomy was eventually performed after almost 10 episodes of IR. Intraoperatively, distal ileum thickening with palpable masses without bowel necrosis and perforation was noted. ILH was suspected and a biopsy of the affected intestine was performed. Histopathological analysis confirmed ILH. The intussusception was manually reduced, the terminal ileum and the ileocecal junction were fixed to the paralleled ascending colon and the posterior peritoneum respectively, and no bowel resection was performed. The postoperative recovery was uneventful and no IR was observed during over 5 years of follow-up. CONCLUSIONS: As far as we are aware, this is the first report of successful surgical treatment of ILH-induced pediatric IR without bowel resection in a child. Our experience suggests bowel resection may be unnecessary if bowel necrosis and perforation are absent.

Lipid enemas for meconium evacuation in preterm infants - a retrospective cohort study.

BACKGROUND: Enemas are used in preterm infants to promote meconium evacuation, but frequent high-volume enemas might contribute to focal intestinal perforation (FIP). To replace a regime consisting of frequent enemas of varying volume and composition, we implemented a once-daily, low-volume lipid enema (LE) regimen. We investigated its impact on meconium evacuation, enteral nutrition, and gastrointestinal complications in preterm infants. METHODS: We performed a single-center retrospective study comparing cohorts of preterm infants < 28 weeks gestation or < 32 weeks, but with birth weight < 10th percentile, before and after implementing LE. Outcomes were rates of FIP, necrotizing enterocolitis (NEC), and sepsis. We assessed stooling patterns, early enteral and parenteral nutrition. We used descriptive statistics for group comparisons and logistic regression to identify associations between LE and gastrointestinal complications and to adjust for group imbalances and potential confounders. Exclusion criteria were gastrointestinal malformations or pre-determined palliative care. RESULTS: Data from 399 infants were analyzed, 203 before vs. 190 after implementing LE; in the latter period, 55 protocol deviations occurred where infants received no enema, resulting in 3 groups with either variable enemas, LE or no enema use. Rates of FIP and sepsis were 11.9% vs. 6.4% vs. 0.0% and 18.4% vs. 13.5% vs. 14.0%, respectively. NEC rates were 3.0% vs. 7.8% vs. 3.5%. Adjusted for confounders, LE had no effect on FIP risk (aOR 1.1; 95%CI 0.5-2.8; p = 0.80), but was associated with an increased risk of NEC (aOR 2.9; 95%CI 1.0-8.6; p = 0.048). While fewer enemas were applied in the LE group resulting in a prolonged meconium passage, no changes in early enteral and parenteral nutrition were observed. We identified indomethacin administration and formula feeding as additional risk factors for FIP and NEC, respectively (aOR 3.5; 95%CI 1.5-8.3; p < 0.01 and aOR 3.4; 95%CI 1.2-9.3; p = 0.02). CONCLUSION: Implementing LE had no clinically significant impact on meconium evacuation, early enteral or parenteral nutrition. FIP and sepsis rates remained unaffected. Other changes in clinical practice, like a reduced use of indomethacin, possibly affected FIP rates in our cohorts. The association between LE and NEC found here argues against further adoption of this practice. TRIAL REGISTRATION: Registered at the German Register of Clinical Trials (no. DRKS00024021 ; Feb 022021).

Ileal neoappendicostomy for antegrade colonic enema (ACE) in the treatment of fecal incontinence and chronic constipation: a systematic review.

BACKGROUND: Antegrade colonic enema (ACE) via an appendicostomy is a recognised method of treatment for medically intractable fecal incontinence and/or constipation. In case of a missing appendix, ileal neoappendicostomy (INA) is considered a suitable alternative. The aim of this study was to review the postoperative complications, functional outcome, stoma-related complications and quality of life of patients treated with this method. METHODS: A systematic literature search was performed in Embase, MEDLINE, PubMed (NCBI) and Cochrane Library from inception to September 2020 using the search terms "antegrade enema" OR "continence enema". Studies on children and adults with fecal incontinence, constipation or a combination of both, who underwent ileal neoappendicostomy for ACE due to the failure of medical treatment and/or anal irrigation were included in the studies, which reported one or more of the following primary outcomes: postoperative complications, functional results, and stoma-related complications. RESULTS: A total of 780 studies were identified, 8 of which, comprising 6 studies in adults and 2 in children, were eligible for review. Overall, 139 patients were included. All studies were retrospective and the methods for reporting outcomes were highly heterogeneous. Improvements in incontinence and constipation were reported in all studies, together with an improved quality of life when reported (5 studies). Stomal stenosis and leakage rates were 0-29% and 14-60%, respectively. Postoperative complications were relatively common and included potentially life-threatening complications. CONCLUSIONS: Taking into consideration that studies of INA were few and of poorly quality; ACE via an INA had a positive impact on bowel function and quality of life. Stoma-related complications and postoperative complications remain a concern.

[A case of hemolysis and acute kidney disease caused by rectal damage due to glycerin enema].

A male patient in his sixties with a long-term history of schizophrenia had been received glycerin enema once or twice a week in a mental hospital. He was emergently transferred to our hospital due to fever, vomiting, hematuria, and dyspnea. Laboratory findings on admission showed an elevation of white blood cells indicating inflammation, hemolysis, and renal dysfunction. Plain CT showed pleural effusion and ascites, elevated levels of perirectal fat, in addition to extraintestinal gas. Based on these findings, he was diagnosed with rectal damage caused by the glycerin enema and associated hemolysis with acute renal failure. He was kept under conditions of nil by mouth and received intravenous antibiotics, diuretic drug, and haptoglobin. Eventually, his condition improved with these conservative therapies. In this case, it is assumed that the hemolysis was caused by the influx of glycerin in the cytoplasm and an increase of osmotic pressure. Care should be taken during glycerin enema, which is widely used in daily practice as well as in home care settings.

Gastrointestinal Bleeding in Patients With Coronavirus Disease 2019: A Matched Case-Control Study.

INTRODUCTION: Although current literature has addressed gastrointestinal presentations including nausea, vomiting, diarrhea, abnormal liver chemistries, and hyperlipasemia as possible coronavirus disease 2019 (COVID-19) manifestations, the risk and type of gastrointestinal bleeding (GIB) in this population is not well characterized. METHODS: This is a matched case-control (1:2) study with 41 cases of GIB (31 upper and 10 lower) in patients with COVID-19 and 82 matched controls of patients with COVID-19 without GIB. The primary objective was to characterize bleeding etiologies, and our secondary aim was to discuss outcomes and therapeutic approaches. RESULTS: There was no difference in the presenting symptoms of the cases and controls, and no difference in severity of COVID-19 manifestations (P > 0.05) was observed. Ten (32%) patients with upper GIB underwent esophagogastroduodenoscopy and 5 (50%) patients with lower GIBs underwent flexible sigmoidoscopy or colonoscopy. The most common upper and lower GIB etiologies were gastric or duodenal ulcers (80%) and rectal ulcers related to rectal tubes (60%), respectively. Four of the esophagogastroduodenoscopies resulted in therapeutic interventions, and the 3 patients with rectal ulcers were referred to colorectal surgery for rectal packing. Successful hemostasis was achieved in all 7 cases that required interventions. Transfusion requirements between patients who underwent endoscopic therapy and those who were conservatively managed were not significantly different. Anticoagulation and rectal tube usage trended toward being a risk factor for GIB, although it did not reach statistical significance. DISCUSSION: In COVID-19 patients with GIB, compared with matched controls of COVID-19 patients without GIB, there seemed to be no difference in initial presenting symptoms. Of those with upper and lower GIB, the most common etiology was peptic ulcer disease and rectal ulcers from rectal tubes, respectively. Conservative management seems to be a reasonable initial approach in managing these complex cases, but larger studies are needed to guide management.

The tip of the iceberg of colorectal perforation from enema: a systematic review and meta-analysis.

BACKGROUND: Although rare, perforation following an enema used to treat constipation is a dangerous complication. However, no recommendations or guidelines for enema use are available. So, in common clinical practice, the diagnostic approach and the treatment are not standardized. In an attempt to resolve this clinical dilemma associated with high mortality and potential medicolegal claims for malpractice, we have performed a systematic review and meta-analysis of studies reporting on colorectal perforation secondary to enema use for adult patients with constipation. METHODS: A systematic search of PubMed, Web of Science and Scopus was performed according to the PRISMA statement up until February 2020. Studies that reported on colorectal perforation from enema use in adult patients with constipation were included. The primary outcomes were the rate of hospital mortality and pooled prevalence estimates of mortality from perforation secondary to enema use. The secondary outcomes were the administration of rectal enemas, site of visceral perforation, signs, symptoms, radiological evaluation, and type of treatment RESULTS: A total of 15 studies were included in the final analysis (49 patients). Across all studies, the pooled prevalence estimate of mortality for patients with perforation secondary to enema use was 38.5%, (95% CI [22.7%, 55.5%]). This rate was lower in patients who had surgery (35%) than in patients treated conservatively (57.1%). The sites of perforation were intraoperatively reported in 84% of cases, but in 16% of patients the rectal perforation was undiagnosed, and surgical decision making was problematic. The primary location of the perforation was the rectum in 80.9% of the patients. The enema was administered by a nurse in 90% of the cases, self-administered in 7.5% and a family doctor in 2.5%. The main objective of emergency surgery in this setting is resection of the perforation caused by the enema; when it is not possible to resect the perforated rectum, faecal diversion is needed. Hartmann's procedure was most commonly performed by the surgeons in this review (60.7%), with other reported treatments included a diverting proximal loop colostomy and sigmoid segment exteriorization CONCLUSIONS: Considering the studies available, it is not possible to undertake a thorough evaluation of enema use, including the associated complications and their management. Further data are required to allow the development of guidelines to advice on safe enema use and management of complications.

Prevention and management of complications in various antegrade enema procedures in children: a review of the literature.

The antegrade continence enema (ACE) procedures are successful surgical options to achieve bowel cleaning in children with faecal incontinence due to a neuropathy or an anorectal malformation and an intractable constipation. The reversed and orthotopic appendicocecostomy, tubularized ileal conduit and the tubularized cecal flap are frequently applied procedures in the treatment of faecal incontinence (FI). The most common complications are the stoma stenosis, leakage, prolapse, adhesive obstruction and the difficulty in catheterization. Each procedure has its own advantages and disadvantages with different complication rates. The postoperative complications of ACE procedures may reduce patient compliance and quality of life. Most of these complications can be preventable and are easy to manage. This review aimed to discuss the prevention and management strategies for various ACE procedure complications.

Management of Intussusception in the Pediatric Emergency Department: Risk Factors for Recurrence.

BACKGROUND: The standard treatment for intussusception is air reduction enema (ARE) with inpatient observation for 24 to 48 hours to monitor for recurrence. More recent but limited observations suggest that patients who have undergone successful ARE can safely be discharged after 4 to 6 hours of observation. Our primary objective was to identify risk factors associated with early recurrence. Our secondary objectives included validating risk criteria from prior studies and identifying risk factors for ARE failures. DESIGN/METHODS: A retrospective cohort study of children discharged from a large urban quaternary hospital with a final diagnosis of intussusception (International Classification of Diseases, Ninth Revision, code 560.0) or who underwent ARE from 2005 to 2015 was identified. Demographic data, radiology images, and clinical course were recorded. Repeat visits, cases with incomplete medical records, and those with incorrect diagnoses were excluded. RESULTS: A total of 250 cases were identified. Two hundred cases were included for analysis. Fifty were excluded. Of the 163 who had successful reduction with ARE, 22 patients (13.5%) recurred, and 12 (7.3%) recurred within 48 hours. Fever (odds ratio, 4.25; P = 0.04; 95% confidence interval, 1.04-17.3) and female sex (odds ratio, 7.94; P = 0.01; 95% confidence interval, 1.82-34.6) were independently associated with early recurrence. No radiologic features were associated with early recurrence. CONCLUSIONS: Early recurrence after successful ARE was low, although more frequent in girls and in those with fever over 100.4°F. We therefore advocate for prospective studies to validate these risk criteria to identify patients who are at low risk for early recurrence and may qualify for early discharge from the emergency department.

Can intussusceptions of small bowel and colon be transient? A prospective study.

We performed a prospective study to explore a diagnosis and treatment protocol of transient intussusception in children (TIC). Totally, 143 children with intussusception who met the inclusion criteria were firstly divided into intussusception involving only the small bowel and intussusception involving the colon group. And in each group, they were further divided into short-segment (≤ 3.0 cm) and long-segment (> 3.0 cm) groups according to the length of intussusception. After a period of conservative treatment, the incidence of TIC, the incidence of surgery, and recurrence were collected and analyzed. Finally, we found that the incidence of TIC in the short-segment group of small bowel intussusception (96.29%) was significantly higher than that in other groups (P ≤ 0.001). Besides, the incidence of surgery and recurrence in this group was relatively low too. Therefore, we summarized the inclusion criteria and treatments to the short-segment group of small bowel intussusception as the suggested protocol to TIC.Conclusion: For cases of small bowel intussusception with no identified pathologic lead point, a short duration of symptoms, a length of ≤ 3.0 cm, a relatively abundant vascular flow signal, and a stable general condition, the spontaneous reduction could be expected and a period of conservative treatment with careful monitoring is recommended. What is Known: • The phenomenon of spontaneous reduction in intussusception (transient intussusception) among pediatric patients has been widely reported. • To distinguish the transient intussusception from the other types is important for the transient ones only need conservative treatment rather than enema reduction or surgery. What is New: • This is the first prospective study to explore a diagnosis and treatment protocol of transient intussusception in children. • Short-segment small bowel intussusceptions have a higher rate (96.29%) to get spontaneous reduction than the other types of intussusception.

An Emergency Department Presentation of Severe Colitis After a Home Hydrogen Peroxide Enema.

BACKGROUND: Health information found on open access Internet platforms is often unscrutinized, unreliable, and can lead to considerable morbidity for patients and their presentation to the emergency department. Currently, home treatments for constipation and other gastrointestinal ailments featuring the use of hydrogen peroxide (H2O2) enemas are readily available. CASE REPORT: We present a case of a 48-year-old female with a history of fibroids who presented to the emergency department with acute abdominal pain after self-administering a 3% H2O2 enema, which she learned about on the Internet as a treatment for constipation. She subsequently developed a severe colitis with evidence of pneumatosis and focal perforation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although toxicity from oral ingestions of H2O2 is well described in the literature, there are few reports of the sequelae related to rectal administration. Due to its significant morbidity and the public health concerns related to this mechanism of toxicity, emergency physicians are at the frontlines for diagnosing and properly managing these patients. This case report reviews the patient's presentation, findings, and management.

Sonographic Evaluation and Monitoring of Pneumoperitoneum After Air Enema Reduction for Intussusception.

Abdominal radiography and computed tomography scans are standard tests to diagnose pneumoperitoneum. With the growing availability of point-of-care ultrasound, pneumoperitoneum may be diagnosed in settings without easy access to radiography or computed tomography, such as in overcrowded emergency departments or resource-poor environments. The use of point-of-care ultrasound to diagnose or monitor pneumoperitoneum has been described in adult but not pediatric patients. We present a case of point-of-care ultrasound detection of pneumoperitoneum and monitoring for tension pneumoperitoneum, after failed air enema reduction for intussusception in an infant.

EFFECT OF A NUTRIENT ENEMA ON SERUM NUTRIENT CONCENTRATIONS IN WHITE-SPOTTED BAMBOO SHARKS (CHILOSCYLLIUM PLAGIOSUM).

Ill and anorectic captive sharks present a unique challenge for husbandry and veterinary staff. Providing adequate fluid and nutritional support to sharks while minimizing handling remains difficult. This study aimed to evaluate the ability of a nutrient enema to alter blood analyte concentrations. Thirty-six healthy, fasted white-spotted bamboo sharks (Chiloscyllium plagiosum) were enrolled in the study with 18 sharks receiving a nutrient enema and 18 sharks receiving a non-nutrient saline enema. The metabolic state of sharks was evaluated via measurement of blood glucose, blood urea nitrogen, and ß-hydroxybutyrate as well as other serum biochemistry parameters. Changes in sodium, chloride, calcium, ß-hydroxybutyrate, glucose, total protein, and triglyceride concentrations were seen across time in both groups. Blood glucose absolute concentrations and changes over time differed between the nutrient and nonnutrient groups. This pilot study indicates that it is possible to influence the glucose metabolism of healthy sharks via nutrient enema. Further study is needed to better understand potential therapeutics for ill and anorectic sharks.

Effect of rectal douching/enema on rectal gonorrhoea and chlamydia among a cohort of men who have sex with men on HIV pre-exposure prophylaxis.

OBJECTIVES: Rectal douching/enema (RD) is a common practice among men who have sex with men (MSM) in preparation for sex. RD can break down the rectal mucosal barrier and potentially affect the rectal microbiome. The objective of this study was to understand if RD is associated with acquiring rectal infections (RI) with rectal gonorrhoea (NG) and/or chlamydia (CT). METHODS: From 2013 to 2015, 395 adult HIV-uninfected MSM were enrolled in a randomised controlled study for pre-exposure prophylaxis (PrEP) adherence with routine sexual risk survey and testing. Using data from this cohort, baseline differences by RI were assessed using Pearson's χ² and Wilcoxon-Mann-Whitney test. Association between RD and RI was modelled using multivariable logistic regression adjusted for potential confounders (sexual behaviour, substance use and age) selected a priori. Effect modification by number of male partners and sensitivity analysis to rule out reverse causality were also conducted. RESULTS: Of 395 participants, 261 (66%) performed RD and 133 (33%) had at least one NG/CT RI over 48 weeks. Number of condomless anal receptive sex (med: 4, p<0.001), male partners (med:6, p<0.001) and substance use (any of methamphetamine/hallucinogens/dissociative/poppers) (p<0.001) were associated with increased odds of RI. Controlling for potential confounders, odds of prevalent RI were 3.59 (p<0.001, 95% CI 1.90 to 6.78) and incident RI 3.87 (p=0.001, 95% CI 1.78 to 8.39) when douching weekly or more compared with not douching. MSM with more than six male partners had 5.34 (p=0.002, 95% CI 1.87 to 15.31) increased odds of RI when douching weekly or more compared with not douching. CONCLUSION: Rectal hygiene with RD is a common practice (66%) among HIV-uninfected MSM on PrEP in this study, which increases the odds of acquiring rectal NG and/or CT independent of sexual risk behaviour, substance use and other factors. This suggests interventional approaches targeting rectal hygiene products and practices could reduce sexually transmitted infections.