inforMED

GENT-L-KARE

Received May 9, 2019 · Event occurred Mar 20, 2019

Report MW5086537 · MDR key 8600384

Device

Generic name

Enema Kit

Model number

107037

Lot number

1060371024

Product problems

  • Use of Device Problem

Patient

57 YR

  • Ulceration
  • Ulceration

Narrative

Description of Event or Problem

PT CAME TO GI LAB FOR FLEXIBLE SIGMOIDOSCOPY. WHEN PROCEDURE STARTED AND SCOPE INSERTED, A CAP FROM AN ENEMA WAS FOUND APPROX 2 INCHES INTO RECTUM. PT SUSTAINED MUCOSAL ULCERATION FROM THE CAP OF AN ENEMA. WE UNDERSTAND THIS WAS USER ERROR AS ENEMA CAP WAS NOT REMOVED BEFORE ENEMA GIVEN. ALTHOUGH, WE FELT THIS WAS A REPORTABLE EVENT AS THE TUBING AND ENEMA CAP ARE THE SAME COLOR - BLUE. FDA SAFETY REPORT ID# (B)(4).