Journal of Emergencies, Trauma, and Shock
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
Users online:151   Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size   


 
 Table of Contents    
CASE REPORT  
Year : 2013  |  Volume : 6  |  Issue : 1  |  Page : 56-57
Blunt abdominal trauma with transanal small bowel evisceration


1 Department of General Surgery, Calicut Medical College, Kozhikode, Kerala, India
2 Department of General Surgery, Thiruvananthapuram Medical College, Trivandrum, Kerala, India

Click here for correspondence address and email

Date of Submission15-Dec-2011
Date of Acceptance15-Apr-2012
Date of Web Publication22-Jan-2013
 

   Abstract 

Small bowel evisceration through the anus can occur spontaneously or post traumatically. Traumatic transanal small bowel evisceration results from iatrogenic injuries, suction injuries, and blunt abdominal trauma (BAT). We report a 48-year-old female who presented with evisceration of small intestinal loops through the anus following BAT and discuss the etiologies and mechanisms of injury of this rare presentation.

Keywords: Blunt abdominal trauma, evisceration, perforation

How to cite this article:
Medappil N, Prashanth AK, Latheef A. Blunt abdominal trauma with transanal small bowel evisceration. J Emerg Trauma Shock 2013;6:56-7

How to cite this URL:
Medappil N, Prashanth AK, Latheef A. Blunt abdominal trauma with transanal small bowel evisceration. J Emerg Trauma Shock [serial online] 2013 [cited 2019 Jul 21];6:56-7. Available from: http://www.onlinejets.org/text.asp?2013/6/1/56/106328



   Introduction Top


Most of the blunt abdominal injuries result from road traffic accidents, and majority of the patients have multisystem injuries. The incidence of major intestinal injuries among patients sustaining blunt abdominal trauma (BAT) ranges from 5-15% in various series. Transanal small bowel evisceration (TSBE) following BAT results from associated rectal or rectosigmoid perforation and requires special mention due to its extraordinary presentation. Early recognition of bowel injuries can be difficult and a high grade of suspicion is mandatory.


   Case Report Top


A 48-year-old female presented to the emergency department with complaints of severe abdominal pain and protrusion of bowel loops through the anus. She gave a history of assault with a direct kick over the lower abdomen 8 hours before presentation. On presentation, she was conscious with a pulse rate of 98/minute and blood pressure of 100/60 mmHg. The abdomen was tender with mild guarding. Loops of congested small intestine were seen protruding through the anus [Figure 1]. There were no other associated injuries or hematuria. The patient was resuscitated and transferred for urgent laparotomy. During laparotomy, a longitudinal rent was seen at the antimesenteric border of rectosigmoid region [Figure 2] with ileal loops entering the large bowel lumen. There was no hemoperitoneum or fecal contamination of peritoneal cavity. No other solid organ injury was detected. Small bowel loops were gently reduced in the abdominal cavity; warm moist packs applied and viability ascertained. Primary closure of sigmoid done in two layers and abdomen closed after thorough peritoneal lavage. The patient was under intensive care for 48 hours and discharged on the seventh postoperative day. The patient is healthy on two months follow-up.
Figure 1: Congested small bowel loops eviscerated transanally

Click here to view
Figure 2: Intraoperative image showing perforation of rectosigmoid region with clean peritoneal cavity

Click here to view



   Discussion Top


Rectosigmoid perforation with TSBE is rare and occurs spontaneously or post traumatically. The first case of small bowel evisceration through the anus was reported by Brodie in 1827. [1] Of the nearly 70 cases reported till date, majority occurred spontaneously in elderly patients. Spontaneous perforation of rectum is more commonly reported in elderly females and majority had associated rectal prolapse. [2] Straining with defecation, chronic constipation, enteroptosis and rectal ulcerations were the predisposing factors with spontaneous perforation. Traumatic rectosigmoid perforation has been reported from BAT, suction injuries, and iatrogenic injuries following reduction of rectal prolapse. [3],[4],[5]

Though intestine is the third most commonly injured organ in BAT, colonic injuries account for only 3-5% and occur less frequently than that of the small bowel. [6] The proposed mechanisms of intestinal injury in BAT include compression forces and deceleration forces. Compression forces result from direct blow or impingement between the vertebrae and anterior abdominal wall, which result in sudden increase in the intraluminal pressure of the intestine and rupture. Increased intraabdominal pressure can also increase the intraluminal pressure and pressures more than 150-260 mmHg can rupture the intestinal loops. Deceleration forces result in tangential tears at the relatively fixed points of the bowel such as the duodenum, right colon, and left colon. [6],[7]

The type of injury varies from intramural hematoma to perforation and partially correlates with the mechanism of injury. Intramural hematomas affect duodenum more commonly than colon and are recently diagnosed more frequently with the introduction of computed tomography imaging. Serosal tears occur frequently in the transverse colon due to its vulnerable location in proximity to spine and impingement of the colon between the anterior abdominal wall and the lumbar spine. Acute perforations are more common in the sigmoid colon, probably due to the redundancy, which makes it susceptible to closed-loop formation. Proximal jejunum and distal ileum are more prone to perforation in the small intestine. [6],[7]

Clinical features are vague at initial presentation and become obvious only at repeated abdominal examination in the observation room. Duodenal and jejunal hematomas present with obstructive features. Colonic hematomas present with rectal bleeding or shock due to retroperitoneal evacuation of the hematoma and colonic perforation presents with features of peritonitis. Fecal contamination of the peritoneal cavity in colonic perforation with TSBE will be minimal in most cases due to plugging of the rectal rent by the prolapsed small bowel loops. [4] This may result in minimal symptoms and a delayed presentation, as in our case where the patient seeked medical attention only after noticing bowel loops through the anus. Management consists of immediate exploratory laparotomy with careful reduction of small bowel loops in the abdominal cavity. Rectosigmoid tear is usually longitudinal at the antimesenteric border. [4],[5] Gangrenous small bowel segments should be resected and defect in the rectosigmoid repaired primarily. Proximal diverting colostomy should be selectively performed on the basis of the degree of peritoneal contamination and severity of injury. Successful laparoscopic repair of rectosigmoid rupture with TSBE has also been reported. [8] We performed a primary repair as there was a longitudinal defect at the rectosigmoid with minimal peritoneal contamination.


   Conclusion Top


An overlooked bowel injury following BAT results in increased morbidity and mortality because of the tremendous infectious potential. Early recognition and timely surgical intervention offers the best prognosis.

 
   References Top

1.Brodie BC. A case of a singular variety of hernia treated at St. George's Hospital. London Medical and Physical Journal 1827;57:529-30  Back to cited text no. 1
    
2.De Vogel PL, Kamstra PE. Rupture of the rectum with evisceration of small intestine through the anus: A complication of advanced rectal prolapse. Case report. Eur J Surg 1994;160:187-8.  Back to cited text no. 2
[PUBMED]    
3.Hovey MA, Metcalf AM. Incarcerated rectal prolapse-rupture and ileal evisceration after failed reduction: Report of a case. Dis Colon Rectum 1997;40:1254-7.  Back to cited text no. 3
[PUBMED]    
4.Adisa AC, Onyegbule C, Mbanaso AU. Transanal evisceration of the small bowel from blunt abdominal trauma. Niger J Surg Res 2006;8:182-4.  Back to cited text no. 4
    
5.Morris AM, Setty SP, Standage BA, Hansen PD. Acute transanal evisceration of the small bowel: Report of a case and review of the literature. Dis Colon Rectum 2003;46:1280-3.  Back to cited text no. 5
[PUBMED]    
6.Vance BM. Traumatic lesions of the intestine caused by nonpenetrating blunt force. Arch Surg 1923;7:197-212.  Back to cited text no. 6
    
7.Strate RG, Grieco JG. Blunt injury to the colon and rectum. J Trauma 1983;23:384-8.  Back to cited text no. 7
[PUBMED]    
8.Antony MT, Memon MA. Successful laparoscopic repair of spontaneous rectosigmoid rupture with an acute transanal small bowel evisceration. Surg Laparosc Endosc Percutan Tech 2005;15:172-3.  Back to cited text no. 8
[PUBMED]    

Top
Correspondence Address:
Noushif Medappil
Department of General Surgery, Calicut Medical College, Kozhikode, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.106328

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]

This article has been cited by
1 Transanal evisceration of small bowel-a rare surgical emergency
Narayana Swamy Chetty, Y.V., Sridhar, M., Pankaja, S.S.
Journal of Clinical and Diagnostic Research. 2014; 8(1): 183-184
[Pubmed]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed3073    
    Printed106    
    Emailed0    
    PDF Downloaded16    
    Comments [Add]    
    Cited by others 1    

Recommend this journal