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• W2115113721 abstract "The rectal administration of medications offers many advantages, especially in children, including facilitating administration of unpalatable drugs, providing for rapid absorption of the drug, and risking little or no danger of accidental intoxication after self-administration. We report the case of a 4-year-old girl, with acute rectal bleeding and tenesmus after administration of suppositories containing acetylsalicylic acid (ASA), paracetamol, and codeine phosphate. CASE REPORT A healthy 4-year-old girl with no familial or personal history of atopic disease was admitted because of acute rectal bleeding and tenesmus. Three days before, she had been treated for a high fever and an upper respiratory tract infection with antipyretic drugs administered rectally. Three suppositories, containing 150 mg ASA, 50 mg paracetamol and 5 mg codeine phosphate, were given at regular intervals of 4 to 6 hours. The fever persisted for approximately 48 hours. Twelve hours after administration of the third suppository, she developed acute anal pain, tenesmus, and anal bleeding. She did not vomit and did not complain of abdominal pain. Antibiotics (oral amoxycillin and clavulanate acid) were administered without investigation, because of the suspicion of infectious colitis. Because the rectal bleeding persisted in the absence of diarrhea, she was referred for colonoscopy. During clinical examination her temperature was 36.7°C, with some aqueous rhinorrhea and a discrete pharyngeal inflammation. Abdominal findings were normal, including peristalsis. External anal lesions were not detected. Laboratory data were as follows: white blood cell count 4.7 × 103/l (45% neutrophils), platelets 221 × 103/mm3, red blood cells 4.7 × 106, and hemoglobin 12.6 g/dl. Sedimentation rate was 14 mm/hour and C-reactive protein was less than 7 mg/l. Blood chemistry produced normal results, with serum glutamic-oxaloacetic and glutamate pyruvate transminases at 45 and 26 IU/l, respectively, (normal range, <75 IU/l). Coagulation was within normal ranges. Fecal cultures for enteropathogens were not contributive. A fiberoptic rectosigmoidoscopy demonstrated edema of the rectal mucosa with hyperemia and ulcers within 3 to 4 cm from the anal margin. The mucosa of the rest of the rectum and of the left colon was normal. Microscopic examination of the biopsy specimens confirmed the macroscopic findings: ulcers and ischemic lesions were seen in the specimens from the distal 3 to 4 cm of the anal margin; the histology of the biopsies of the colon descendens produced normal results. The findings on rectoscopy and histology strongly suggested an acute hemorrhagic ulcerative proctitis, induced by ASA. The child was discharged without any local or systematic treatment. Symptoms resolved spontaneously and rectosigmoidoscopy, repeated 1 week later, showed an almost normal rectal mucosa with moderate hyperemia but without any ulcer. Histology findings were also normal. Eight months later, symptoms had not relapsed. DISCUSSION The relation between the use of nonsteroidal antiinflammatory drugs, especially ASA, and upper gastrointestinal mucosal lesions is well known. The lesions vary from petechiae and superficial erosions to significant ulcers (1,2). The pathophysiological mechanisms are still controversial: interference with the prostaglandin metabolism, (3,4), ischemia of the gastric epithelium (5), and a deficiency in the macromolecular glycoproteins of the gastric mucus (6) are suggested. In our patient, endoscopic examination of the rectum and colon showed significant, sharply demarcated ulcers, with ischemia and ulceration in histologic findings but no partial necrosis of the mucosa, contrary to the case report by Levy (7). There was no infiltration of eosinophils. Findings in histology of the lesions revealed them to be similar to lesions of the gastric mucosa, which are known to be caused by the oral intake of ASA. Mucosal lesions related to the administration of paracetamol and codeine phosphate have not been reported up to now. Our findings also suggest a direct chemical attack by ASA on the rectal mucosa. Anorectal ulcers have been described in adult women who chronically abuse analgetic suppositories containing ASA, acetaminophen, and codeine (8,9). Such symptoms as anal pain, rectal tenesmus, or bleeding are frequently reported. In these women, rectoscopy has revealed superficial erosions, fibrotic scar lesions, and rectal stenosis located within 8 cm of the anal margin. In these cases, nonspecific inflammation limited to the rectum was found on analysis of biopsy specimens. The hypothesis of a depletion in mucosal prostaglandings was proposed (8). Few case reports are published regarding side effects of drugs administered by rectal route in children. Ueda et al. reported the case of a 9-year-old boy with acute hemorrhagic proctitis, induced by an aminophylline suppository (10), and a challenge confirmed the diagnosis. Proctosigmoidoscopy demonstrated edema of the rectal mucosa with hyperhemia and petechiae. Aminophylline directly affecting the intestinal mucosa has seldom been described. Allergic proctitis is more frequent but could not be confirmed in this patient. The absence of eosinophils revealed by microscopic examination, the negative lymphocyte stimulation test, and the presence of erosions of the mucosa in biopsy specimens suggest a direct irritating effect of aminophylline on the rectal mucosa. Levy described a 15-year-old boy, developing upper gastrointestinal bleeding caused by a duodenal ulcer, related to a 3-year, constant regimen of steroids and salicylates because of rheumatoid arthritis. Indomethacin suppositories were prescribed in a dosage of 50 mg three times daily (7). Six months later, the boy had rectal bleeding, and rectosigmoidoscopy showed severe inflammation of the mucosa with profuse bleeding in the distal 12 cm. This observation illustrates very well that nonsteroidal antiinflammatory drugs can provoke, in the same patient, lesions in the upper and lower gastrointestinal tract. Symptoms seemed dose-related, because inflammation became less pronounced and bleeding stopped when the intake was limited to one suppository daily. In our patient, symptoms had started within 12 hours after administration of only three suppositories containing ASA. The child received a correct dose of 10 mg/kg every 4 to 6 hours. Suppositories containing paracetamol and ASA are widely used in children. To our knowledge, this is the first case report in children indicating a side effect of the administration of ASA (paracetamol and codeine phosphate) by rectal route. The rectal administration of analgesic or antipyretic suppositories in children is an efficacious and safe method of treatment; but in the presence of anal pain, rectal bleeding, and tenesmus an acute, rectal hemorrhagic ulcerative proctitis induced by ASA should be considered." @default.
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• W2115113721 title "Ulcers of the Rectal Mucosa Caused by Suppositories Containing Acetylsalicylic Acid" @default.
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