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Year : 2022  |  Volume : 3  |  Issue : 2  |  Page : 164-166

Necrotic rectal prolapse with perforation and herniation of small bowel, treated with abdominoperineal resection

1 Department of General Surgery, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
2 Norwich Medical School, University of East Anglia, Norwich, UK

Date of Submission06-Nov-2020
Date of Decision09-Feb-2021
Date of Acceptance27-Mar-2021
Date of Web Publication29-Aug-2022

Correspondence Address:
Dr. Melissa M Gabriel
Department of General Surgery, Norfolk and Norwich University Hospital, Norwich
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_183_20

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How to cite this article:
Gabriel MM, V. Philippson NS, Horrigan CN, Rankin A, Shaikh IA. Necrotic rectal prolapse with perforation and herniation of small bowel, treated with abdominoperineal resection. J Med Evid 2022;3:164-6

How to cite this URL:
Gabriel MM, V. Philippson NS, Horrigan CN, Rankin A, Shaikh IA. Necrotic rectal prolapse with perforation and herniation of small bowel, treated with abdominoperineal resection. J Med Evid [serial online] 2022 [cited 2022 Oct 5];3:164-6. Available from: http://www.journaljme.org/text.asp?2022/3/2/164/354981

  Introduction Top

Spontaneous bowel perforation and subsequent small bowel evisceration are a very rare presentation to hospital.[1] Blunt force trauma is a more common cause of bowel perforation than spontaneous defect, which can be secondary to diverticular disease, carcinoma of the rectum, or colitis.[1],[2] For either aetiology of bowel perforation, the potential successive evisceration of small bowel can result in a patient deteriorating with complications such as sepsis, peritonitis and damage to the exposed bowel.[2] Management includes rapid identification and transfer to theatre for reduction of the bowel and immediate or delayed correction of the large bowel defect.

This case is unique, not only in the rarity of the clinical presentation but also in the approach to definitive surgical management. Recurrent rectal prolapse and consequent corrective surgery provided challenges for the surgical team. For these reasons, it is important for this case report to highlight the creative surgical management that ultimately kept this patient stable and maximised post-operative quality of life.

  Case Report Top

A 64-year-old woman presented to the emergency department with rectal prolapse complicated by small bowel evisceration. There was a history of recurrent rectal prolapses, for which she had had two previous operations at another hospital, one being a perineal rectosigmoidectomy (Altemeier's procedure). Despite this, she had recurrent prolapses awaiting further repair. Past medical history included uterine prolapse and hysterectomy, hypertension, osteoporosis and mild dementia. The patient experienced rectal prolapse while urinating, 2 hours before presentation to hospital. Previously, the prolapse had been the size of a cricket ball [Figure 1], which had been manually self-reduced. At the time of admission to the emergency department, she had several loops (two metres) of congested but viable and peristalsing small bowel prolapsing through the anal canal [Figure 2]. The patient was in significant pain, hypotensive and tachycardic with cool peripheries. On examination, there was no clinical evidence of small bowel perforation. A venous blood gas showed a respiratory alkalosis, and lactate, renal function and full blood count were all within normal range.
Figure 1: Image demonstrating initial size of prolapse (roughly size of a cricket ball), which the patient was able to self-reduce manually

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Figure 2: Image of small bowel prolapsing through the anal canal in the emergency department

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The patient was initially treated with analgesics, fluid resuscitation, antiemetics and broad-spectrum intravenous antibiotics. The surgical on-call consultant attended and manually reduced the prolapse. It appeared that the small bowel had prolapsed through the anterior rectal wall perforation. Emergency surgery was arranged. Initial laparoscopic omental mobilisation was performed, to be used later to fill the pelvis. The plan was to repair the rectal perforation with stoma formation or a low Hartmann's resection. However, the procedure was converted due poor views in the pelvis and difficulty ascertaining the boundaries of perforation. Additional findings included a very weak pelvic floor and an anterior wall rectal perforation was noted, near to what looked like an anastomosis (previous Altemeier's procedure and another unknown procedure) which had become necrotic. Due to extensive scarring from previous operations, the rectum could not be resected distally; hence, an abdominoperineal resection of the rectum (APER) was performed. The proximal colon was brought out as a permanent stoma.

She initially required inotropic support on the high dependency unit and was moved to a general surgical ward after 24 hours. Broad-spectrum intravenous antibiotics were continued due to risk of small bowel infection. Clear fluids and a soft diet were started 4 days post-operatively. Colostomy started to function less than a week after the operation. She was deemed medically fit for discharge 7 days after the operation, though discharge was delayed due to social circumstances.

  Discussion Top

Evisceration of the small bowel through a rectal perforation is extremely rare, and only a few cases have been reported since the condition was first described by Brodie in 1827.[3] The main cause is considered to be due to sudden raised intra-abdominal pressure and a history of rectal prolapse.[3],[4] In the literature, there are only two reported cases of associated uterine prolapse and one case of rectal and uterine prolapse.[3],[4] In this case report, we describe a patient who had a history of both recurrent rectal prolapse and previous uterine prolapse. She had undergone two previous procedures and was awaiting a third repair for her recurrent rectal prolapse. It is not clear what directly caused her rectal perforation but it may have been attributed to weakness of the anterior wall of the rectosigmoid colon. From the literature, the most likely mechanism is due to a sliding hernia, where the hernia sac (formed of the viscera and the Pouch of Douglas) invaginates the anterior wall of the rectum into the rectal lumen.[3],[5]

Emergency management of the patient included aggressive fluid resuscitation and attempts to reduce the prolapse. Manual reduction is rarely successful and surgical intervention is often warranted.[6] In this case, necrosis may have occurred due to self-reduction of recurrent rectal prolapses.

This is the first reported case of APER as a treatment for rectal perforation and small bowel herniation. Various surgical techniques have been proposed and Shoab et al. suggested Thiersch repair as standard management for elderly patient with spontaneous perforation.[7] Hartmann's colostomy has also been described as a safe option for these patients.[6] In this case, the patient was haemodynamically unstable with a high risk of peritonitis due to the bowel being outside the body for several hours. She required an emergency procedure and was found to have a weak pelvic floor, necrosis and extensive scarring from previous surgeries. She also had some lower rectum and anal canal present despite her previous Altemeier procedure. Proceeding with a low Hartmann's procedure was not possible due to poor views of the pelvis and difficulty determining the borders of the perforation. Ileoanal anastomosis would also not have been appropriate in the emergency setting and would have provided poor bowel function compared to abdominoperineal resection.

This case report describes the rare presentation of evisceration of the small bowel through a rectal perforation in a UK-based hospital. Patients with recurrent rectal prolapse are at high risk of this complication and early emergency management with resuscitation can help to reduce bowel ischaemia. APER can be one of the several management options.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kumar S, Mishra A, Gautam S, Tiwari S. Small bowel evisceration through the anus in rectal prolapse in an Indian male patient. BMJ Case Reports 2013;2013:bcr2013010411.  Back to cited text no. 1
Medappil N, Prashanth AK, Latheef A. Blunt abdominal trauma with transanal small bowel evisceration. J Emerg Trauma Shock 2013;6:56-7.  Back to cited text no. 2
  [Full text]  
Jeong J, Park JS, Byun CG, Yoon DS, Sohn SK, Lee YH, et al. Rupture of the rectosigmoid colon with evisceration of the small bowel through the anus. Yonsei Med J 2000;41:289-92.  Back to cited text no. 3
Shafiroff BB, Carnevale N, Delany HM. Spontaneous rupture of the rectosigmoid colon with anal evisceration: A new complication of uterine prolapse. Surgery 1976;79:360-2.  Back to cited text no. 4
Berwin JT, Ho TK, D'Souza R. Small bowel evisceration through the anus—report of a case and review of literature. BMJ Case Reports, 2012. [doi: 10.1136/bcr. 12.2011.5316].  Back to cited text no. 5
Ahmad A, Kumar S, Sonkar AA, Kumar S. Evisceration of the small bowel through a perforated and prolapsed sigmoid colon: An unusual presentation of rectal prolapse. BMJ Case Reports, 2016;2016:doi 10.1136/bcr-2016-214811.  Back to cited text no. 6
Shoab SS, Saravanan B, Neminathan S, Garsaa T. Thiersch repair of a spontaneous rupture of rectal prolapse with evisceration of small bowel through anus – A case report. Ann R Coll Surg Engl 2007;89:W6-8.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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