P2.M255: Spastic left colon syndrome after long-term, high-volume antegrade continence enema use

Introduction: Antegrade continence enemas (ACE) are a common treatment for fecal incontinence or refractory idiopathic constipation. Although effective for many patients suffering from altered colonic motility, one potential long-term complication of ACEs is “spastic left colon syndrome,” which has been diagnosed in patients on chronic high volume enema therapy with symptoms of abdominal pain with flushes, progressive time needed to pass the effluent, and radiographic evidence on contrast study of a dilated right colon with a spastic left colon. Management strategies have not been described in the literature.

Case Description: We describe four patients with spastic left colon syndrome – two with anorectal malformations (Patient 1 and 2), one with Hirschsprung Disease (Patient 3) and one with spina bifida (Patient 4). Patients 1-3 were asymptomatic on anterograde flushes for 3, 8, and 10 years, respectively, prior to symptoms of fecal urgency and frequency, small volume stools, and prolonged flush times. Patient 1’s symptoms were exacerbated during exercise, Patient 2’s by certain foods, and Patient 3’s by certain foods and exercise akin to Irritable Bowel Syndrome (IBS). Flushes were increased in frequency and volume by patients with no relief. Patients 1 and 2 added loperamide to their regimen with much improvement in symptoms. Patient 3 was able to transition from flushes to senna, and hyoscyamine and loperamide as needed. For patient 4, after 8 years of anterograde enemas, she began having difficulty evacuating her flush and had episodes of incontinence between flushes. Hyoscyamine was added and palliated symptoms.

Discussion: This case series highlights common presenting symptoms as well as management strategies in spastic left colon syndrome. 3 of our 4 patients had symptoms that resembled IBS with frequent, small volume stools in between flushes, with the sensation of incomplete evacuation, that worsened with activity and/or specific foods. All patients had developed prolonged time for flush completion. Management of symptoms were notably very difficult as patients were sensitive to minor changes and thus needed very close follow up. We were able to transition one patient off flushes to a stimulant laxative. The other three required flushes due to underlying anatomy and benefitted from decreasing flush volume and frequency and adding loperamide and hyoscyamine.

Conclusion: Chronic use of high-volume enemas, regardless of preprocedural diagnosis and contents of enema, can lead to spastic left colon syndrome. Patients can present with IBS-like symptoms. Recognition of signs and symptoms in patients is crucial in symptom management. As it is unknown if ongoing enema use would worsen this syndrome, we transitioned off enemas onto a stimulant if the patient was able. Otherwise, decreasing flush volume and frequency with the addition medication to slow colonic motility was the most helpful in management.