eP470 - Small Bowel Evisceration Through Traumatic Rectal Perforation After Ground Level Fall: Management and Surgical Considerations

Purpose/Background: Transanal evisceration of small bowel is a rare complication of rectal perforation that warrants emergent surgical intervention. Few case reports describe this phenomenon, usually associated with chronic rectal prolapse in elderly patients and chronic constipation. Several mechanisms inciting rectal perforation have been described, however they commonly involve a sudden increase in intra-abdominal pressure.1,2 Following rupture, small bowel can then herniate through the rectal wall defect and eviscerate transanally. We present a case of a 90 y/o female who presented with transanal small bowel evisceration after ground level fall.Methods/Interventions: A 90 y/o female with a history of chronic constipation, rectal prolapse, and remote abdominal hysterectomy presented to the emergency department after a ground level fall onto her buttocks about 12 hours prior. She endorsed a history of rectal prolapse of approximately 1 inch of bowel that reduced with minimal effort in the past. This occurrence, however, was much larger and unable to be reduced, prompting presentation. On initial exam the patient was hemodynamically stable with generalized abdominal pain and found to have significant bowel evisceration through her anus. An abdominopelvic CT showed herniation of multiple small bowel loops beneath the pelvic floor externally through the anal sphincter, exiting the peritoneum adjacent to the left lateral aspect of the rectum. She was taken emergently to the operating room for exploratory laparotomy. After careful reduction of the small bowel into the abdominal cavity, a 2x3cm perforation involving 40% circumference of the anterior left lateral wall of the distal rectum was noted. Approximately 100 cm of distal small bowel had strangulated and necrosed from the evisceration, warranting resection with primary anastomosis. After colonic mobilization, the rectum was transected distal and proximal to the perforation and an end colostomy was created.Results/Outcomes: The patient did well postoperatively and was discharged home after diet advancement. In follow up, she reports good management of her ostomy and continues to tolerate a regular diet.Conclusion/

Discussion: Perforation of the rectum occurs as a complication of pathological conditions, such as diverticular disease, carcinoma, colitis, blunt or penetrating trauma, and intraluminal injury3. When presented with eviscerated small bowel, surgical considerations include 1) whether an open or minimally invasive approach should be taken, 2) whether or not the small bowel necessitates resection, 3) whether the rectal defect should be repaired primarily or resected, and 4) whether a colostomy should be created. In this case, the small bowel had been strangulated for >12 hours, which made an open approach with small bowel resection and end colostomy maturation the most feasible option. With prolonged strangulation, the small bowel becomes more friable and edematous making minimally invasive reduction and salvage difficult. The decision between primary repair vs resection of the rectal perforation with or without a colostomy is based on the overall health of the patient, extent of the rectal perforation, and ability to achieve healthy margins after debridement of the defect. The presence of significant rectal prolapse also limits the ability for primary repair as the repair is at risk of continued prolapse and eventual breakdown. Though rare and morbid, favorable outcomes have been documented in the setting of prompt identification and reduction of the eviscerated small bowel.Pre and Post Reduction of Eviscerated Small BowelA. Initial evaluation revealed evisceration of multiple loops of small bowel through the anus - vagina without fistula and perineum in tact.
B. After reduction of the eviscerated small bowel back into the abdomen and resection of necrotic segment, the rectum perforation was clearly visible.