Complicated rectal prolapse in an infant: strangulatedpararectal herniaSunita Singh a,⁎, Anand Pandey a, Shiv Narain Kureel a, Intezar Ahmada,Niraj Kumar Srivastava b
aDepartment of Pediatric Surgery, CSM Medical University (formerly King George's Medical College),Lucknow 226003, IndiabDepartment of Surgery, Railway Hospital, Kanpur 208004, India
Received 8 May 2010; revised 22 July 2010; accepted 2 August 2010
The term rectal prolapse implies a full-thickness circum- bilious vomiting, difficulty in breathing, and a mass
ferential descent of rectum through the anus [1]. Prolapseconsisting of only rectal mucosa is called incomplete ormucosal prolapse. Conservative management should be theinitial approach in all cases. Operative intervention may berequired in recurrent or refractory cases [2]. In children,partial prolapse is more common because the rectal mucosais loosely adherent to the underlying smooth muscle [3]. Wedescribe an extremely rare case of rectal prolapse compli-cated by pararectal hernia, in which the sac was formed bythe adjacent walls of the prolapsed rectum.
1. Case report
An 8-month-old male baby presented to the Department ofPediatric Surgery with complaints of abdominal distension,
protruding through the anus of 3 days duration. Theparents described intermittent protrusion of a mass throughthe anus for the past 2 months that could be reducedmanually. There was a history of chronic cough, recurrentepisodes of diarrhea, and failure to thrive. The parentsconsulted a physician at a primary health care facility whoadvised conservative treatment. For the last 3 days,the prolapsed mass became irreducible and developedbrownish discoloration.
The patient appeared severely dehydrated and malnour-ished (grade IV malnutrition, Indian Academy of Pediatricsclassification [4]). On physical examination, the abdomenwas distended with absent bowel sounds. Examination of theanal region revealed a dusky, edematous, and congestedmass of about 12 cm, protruding through the anus with anopening at its tip (Fig. 1). On palpation, bowel loops werefelt within the prolapsed rectal walls. An erect plainabdominal radiograph suggested the presence of smallbowel obstruction. Laboratory studies showed severe anemia
Fig. 1 Dusky, edematous mass prolapsing through the anus. Thearrow is pointing to the dentate line.
Fig. 3 Pictorial diagram showing pararectal herniation of smallbowel within the sac formed between prolapsed rectal walls. The
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and electrolyte imbalance. Arterial blood gas analysisshowed a hypochloremic metabolic alkalosis.
After intravenous fluid resuscitation, the patient was takento an operating theater. Under general anesthesia, manual
Fig. 2 A, Intraoperative photograph showing dilated small bowelgoing into the hernial sac (vertical arrow) and redundant sigmoidcolon (horizontal arrow) prolapsing through the anus. B, Strangu-lated sigmoid colon. The strangulation occurred because ofcompression by the herniated small bowel. C, Strangulated smallbowel. The strangulation occurred because of vascular compromisein the hernial sac.
horizontal arrow is pointing toward the prolapsed rectosigmoid. Thevertical arrow is pointing toward the herniated small bowel.
reduction of the prolapsed rectal mass was attempted butfailed. A laparotomy was performed, and on exploration, therectum and sigmoid colon were found prolapsing through theanus (Fig. 2A). Small bowel (ileum) 1 ft proximal toileocecal junction had slid into the hernial sac formedbetween the prolapsed walls of the rectum. The large bowelup to descending colon was normal.
The prolapse was reduced forcefully from without inwardinto the peritoneal cavity. This was aided by traction on theprolapsed bowel from inside. After reduction, the sigmoidcolon and ileum were noted to be strangulated (Fig. 2B, C,Fig. 3). The sigmoid colon became strangulated as the result ofa pressure effect of the herniated viscera. An anterior colonresection and resection of the strangulated segment of ileumwas done, and a double-barrel ileostomy was fashioned.Postoperatively, the baby's condition did not improve, andunfortunately, he died on the second postoperative day.
2. Discussion
Complete rectal prolapse is associated with a constellationof distinct anatomic changes, including diastasis of thelevator muscles, deep pouch of Douglas, a redundantrectosigmoid colon, lax lateral and posterior rectal attach-ments, an elongated mesorectum, and loss of the usualhorizontal lie. Of these findings, the most striking change isthe presence of an abnormally deep rectovesical pouch inmales and rectouterine pouch in females [1]. This supportsthe sliding hernia theory of rectal prolapse in which the
pouch of Douglas forms the hernial sac, recessing theanterior rectal wall into the rectal lumen [1]. Currently, as perradiologic studies, intussusception is believed to be theinitiation point of the rectal prolapse [1].
The treatment of choice in partial (mucosal) prolapse issclerotherapy with either 5% phenol in glycerin, hypertonicsaline, or 50% glucose, which induces fibrosis [2,5]. Rectalprolapse may be treated by various surgical techniques oftenwith a successful outcome.[5] Complicated rectal prolapsemay become extremely edematous but often can be manuallyreduced after direct application of sugar (desiccating effect),hyaluronidase, or compression of the prolapsed mass byelastic bandage to decrease edema [5].
In the present case, the infant presented with acomplicated rectal prolapse of 3-day duration. We believethat the factors associated with prolapse in our patient weremultiple episodes of diarrhea, along with chronic cough andlow weight. Children have a more vertical course of rectumwith less prominent angulation [2]. These anatomic pecu-liarities, along with the predisposing factors noted, weremore conducive for the occurrence of prolapse.
Because manual reduction of the prolapse was notpossible even after application of desiccating agent (sugar)or under general anesthesia, surgery had to be performed. Inirreducible cases, perineal rectosigmoidectomy is preferredbecause it reduces the risk of contamination of the peritonealcavity [6-8]. In the present case, however, a laparotomy wasperformed to clarify the cause of associated small bowelobstruction and to aid release of the bowel loops trappedinside the prolapsed rectal walls. Although we had the optionof performing a sigmoid resection and Hartman procedurealong with resection of the strangulated ileum and an end toend ileal anastomosis, because of the poor general condition
of the baby, an anterior resection with proximal divertingdouble-barrel ileostomy was performed.
An extensive search of the literature located only oneother similar case, where a 75-year-old lady developed thesame type of complicated rectal prolapse [6].
Although rectal prolapse is usually a self-limiting problemin children, any child having recurrent episodes of prolapse,and in patients where reduction of the prolapsed rectum isunsuccessful, early operative management is indicated.
References
[1] Shellito PC, Mortensen. Prolapse of the rectum. In: Morris PJ, Malt RA,editors. Oxford textbook of surgery. New York: Oxford MedicalPublication; 1994. p. 1103-10.
[2] Stafford PW. Other disorders of the anus and rectum, anorectal function.In: Grosfeld JL, O'Neil Jr JA, Rowe MI, et al, editors. Pediatric surgery6th edition. Philadelphia (Pa): Mosby Elsevier; 2006. p. 1569-601.
[3] Klein MD, Thomas RP. Surgical conditions of anus, rectum, colon. In:Kliegman RM, Behrman RE, Jenson HB, et al, editors. Nelson textbookof pediatrics. 18th ed. Philadelphia (Pa): Saunders Elsevier; 2007.p. 1635-41.
[4] Gopaldas T, Seshadri S. Nutrition: monitoring and assessment. NewDelhi: Oxford University Press; 1987.
[5] Chan WK, Kay SM, Laberge JM, et al. Injection sclerotherapy in thetreatment of rectal prolapse in infants and children. J Pediatr Surg1998;33:255-8.
[6] Sakaguchi D, Ishida H, Yamada H, et al. Incarcerated recurrent rectalprolapse with ileal strangulation: report of a case. Surg Today 2005;35:415-7.
[7] Yuzbasioglu MF, Bulbuloglu E, Ozkaya M, et al. A different approachto incarcerated and complicated rectal prolapse. Med Sci Monit2008;14:CS60-3.
[8] Ramanujam PS, Venkatesh KS. Management of acute incarceratedrectal prolapse. Dis Colon Rectum 1992;35:1154-6.
