Transanal Evisceration of Small Bowel-A Rare Surgical Emergency

Abstract

A 68-year-old lady was referred to our emergency department, with evisceration of small bowel through anal canal following manual reduction of prolapsed rectum, three days ago. On careful and thorough examination, she was found to be hemodynamically stable. Abdomen was soft and did not show any features suggestive of peritonitis. About three feet of the small bowel with its mesentery was eviscerating through the anal canal which was congested, oedematous and had multiple serosal tears [Table/ Fig-1].In emergency department, the eviscerated bowel was washed copiously with warm saline and covered with moist towels. Broad spectrum antibiotics were given and IV fluids were started. Relevant preoperative work up was done and patient was posted for emergency laparotomy.A lower midline laparotomy was performed, and the eviscerated bowel was gently reduced into the peritoneal cavity with simultaneous support and guidance through the anal canal. After complete reduction of the eviscerated bowel into the peritoneal cavity, a 2x3 cms perforation was noted in the anterior wall of the middle third rectum [Table/ Fig-2]. The margin of perforation was freshened and closed with interrupted polyglactin sutures. A sigmoid loop colostomy was also performed. In view of dilated and congested small bowel with multiple serosal tears, a laparostomy was performed to observe for the integrity and viability of bowel in post-operative period.Immediate post-operative period was uneventful. After 48 hours, saline wash was given through the laparostoma, under epidural analgesia. The bowel appeared normal. However on the fourth post-operative day patient developed breathlessness, bradycardia, hypotension and desaturation with respiratory acidosis. On evaluation she was diagnosed to have acute myocardial infarction with elevated troponin-T levels. The patient was supported with ventilator and inotropes with immediate treatment of the acute myocardial infarction. Despite our prompt response and best supportive care, the patient did not recover from the cardiac insult and succumbed on the twelfth post operative day with multiple organ dysfunction. DIsCUssIoNTransanal evisceration of bowel is a rare complication of chronic prolapse of rectum. This surgical emergency occurs due to herniation of bowel through the breech in the rectal wall. This condition was first described by Brodie in 1827, since then very few cases have been reported [1]. Wrobleski DE, Dailey TH presumed that mainly two factors predispose these patients for this unusual complication. More than 75% of these cases were associated with chronic prolapse of rectum and an event of sudden increase in intra-abdominal pressure [2][3][4]. Broden B, Snellman B with cine-radiographic studies tried to correlate prolapse rectum with perforation. The primary mechanism of rectal prolapse is a sliding hernia, in which the pouch of Douglas and contained viscera form the sac. The hernial sac invaginates the anterior wall of rectum into the rectal lumen resulting in ischemia and the weakening, makin...

A rare surgical emergency - trans anal evisceration of small intestine

“…There were several case reports in the journals indicating the association between the rectal prolapse and trans anal evisceration of the small bowel as in this patient [2,3]. This case report, it illustrates aetiology, management and complications of trans anal evisceration of the small intestine.…”

“…The transanal evisceration of the small bowel is an extremely rare complication [1,2]. This may occur either due to Abdominal and Pelvic trauma especially in young patients or as a result of chronic prolapse of rectum [1,2]. This surgical emergency occurs as a result of herniation of small bowel through the breach in the rectal wall.…”

“…A trans anal evisceration of the small intestine through the anus is a rare surgical emergency [1,2]. This surgical condition may occur spontaneously or associate with rectal injuries [1].…”