Endoscopic Closure of Iatrogenic Rectal Perforation Using the Tulip Bundle Technique : ACG Case Reports Journal

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Endoscopic Closure of Iatrogenic Rectal Perforation Using the Tulip Bundle Technique

Pires, Francisco MD1; Carvalho, Ana Catarina MD1; Araújo, Ricardo MD1

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ACG Case Reports Journal 9(12):p e00898, December 2022. | DOI: 10.14309/crj.0000000000000898


Cleansing enemas are commonly used for constipation, but rectal perforation is a rare complication, with a mean incidence of 0.02%–0.23%.1,2 A 75-year-old woman was referred to the emergency department with severe constipation. Physical examination revealed solid stools in the rectum, and a cleansing enema was applied. Immediately, she presented with abundant hematochezia. Rectosigmoidoscopy revealed a large perforation in the posterior rectal wall because of the tip of the enema. Pelvic computed tomography showed extraluminal air in the perirectal fat, suggestive of rectal perforation (Figure 1). To prevent complications, she was admitted under antibiotics and repeated rectosigmoidoscopy.

Figure 1.:
Pelvic computed tomography showing perirectal free air and fat stranding, suggestive of rectal perforation.

We attempted to close the perforation (Figure 2) using an over-the-scope clip, but it did not adequately fit the defect. Because therapeutical failure was imminent, we performed mucosal closure using a clip-fixed endoloop in a single-channel colonoscope. First, a clip was inserted in the working channel of the endoscope; as an independent device outside the scope, the tip of the endoloop was attached to the clip's teeth; next, the clip and endoloop were housed inside the scope channel until completely hidden, and both the scope and the endoloop were inserted in the rectum. The clip-fixed endoloop was then fixed onto the normal mucosa near the mucosal defect; 3 additional clips were used to anchor the endoloop circumferentially along the tear margins. Finally, the endoloop was tightened to close the perforation (Figure 3). The patient recovered uneventfully and was discharged after 7 days. Two weeks later, only a small scar was identified.

Figure 2.:
Rectosigmoidoscopy revealing a rectal perforation in the posterior rectal wall.
Figure 3.:
Endoscopic closure of the rectal perforation after using an endoloop. The endoloop was anchored with clips to the normal mucosa near the perforation's edges and closed in a purse-string fashion.

An early approach of rectal perforations is critical to prevent complications and reduce mortality.1 Endoscopic techniques, such as over-the-scope clips or through-the-scope clips, are preferred when surgery has high risk of morbimortality.3 New techniques, such as endoloop, have been increasingly used, but choice depends on the type and size of the perforation, available devices, and endoscopist expertise (Video 1, https://links.lww.com/AJG/C770).4,5

Video 1 Endoscopic closure of iatrogenic rectal perforation after a cleansing enema, by using the tulip bundle technique.


Author contributions: F. Pires acquired data, drafted the manuscript, and performed video editing. AC Carvalho acquired data and performed video editing. R. Araújo was responsible for conception and performance of the endoscopic procedure and critically revised the report. All authors read and approved the final version of the manuscript. F. Pires is guarantor of the article.

Financial disclosure: None to report.

Informed consent was obtained for this case report.


1. Lee S, Kwon J, Lee J. Rectal perforations caused by cleansing enemas in chronically constipated patients: Two case reports. SAGE Open Med Case Rep. 2020;8:2050313X2093825.
2. Niv G, Grinberg T, Dickman R, Wasserberg N, Niv Y. Perforation and mortality after cleansing enema for acute constipation are not rare but are preventable. Int J Gen Med. 2013;6:323–8.
3. Jung Y. Endoscopic management of iatrogenic colon perforation. Clin Endosc. 2020;53(1):29–36.
4. Nomura T, Kobayashi M, Morikawa T, Horiki N. Clip-fixed endoloop: An efficacious new method for mucosal defect closure. Endoscopy. 2018;50(6):E126–7.
5. Wang J, Wang X, Liu L, et al. Endoscopic closure of a colonic defect using a novel endoloop system via a single-channel endoscope. Endoscopy. 2016;48(Suppl 1):E142–3.

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© 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.