An adolescent with prolapsed omentum per rectum: Spontaneous rectal perforation managed laparoscopically.

Spontaneous rupture of the rectum is a rare occurrence. A total laparoscopic approach to rectal perforation has only occasionally been reported. We report an unusual case of a young boy who developed a spontaneous rupture of the rectum following a trivial fall. A magnetic resonance imaging revealed a tear in the rectum at the peritoneal reflection with the omentum plugging it. He denied any history of rectal instrumentation or abnormal sexual activity. He had no history of constipation or rectal prolapse. The tear was repaired laparoscopically and a covering loop sigmoid colostomy was added. He made an uneventful post-operative recovery. Spontaneous rupture of the rectum can occur in younger age groups and even in the absence of significant trauma. One needs to diligently bring out a history of rectal trauma. Equally important is to rule out any underlying pathological condition. A laparoscopic approach is feasible, especially in early cases.

INTRODUCTION

Spontaneous rupture of the rectum is a rare occurrence with less than seventy cases being reported in literature.[1] This has to be differentiated from rectal perforations which occur due to underlying pathology or direct rectal trauma. A spontaneous rupture of the rectum is defined as a rectal perforation in the absence of the above two conditions and is usually attributed to a sudden increase in the intra-abdominal and intra-rectal pressures. The traditional management is via a laparotomy with repair of the tear in the rectum with or without a covering colostomy. A total laparoscopic approach to rectal perforation has only occasionally been reported.[2] We report an unusual case of a young boy who developed a spontaneous rupture of the rectum following a trivial fall which was successfully managed laparoscopically.

CASE REPORT

A 17-year-old boy slipped in the bathroom and landed on his gluteal region. When he got up, he developed pain in his lower abdomen and noticed bleeding from his rectum along with mass. He was taken to a nearby hospital where they documented it to be prolapsed omentum which was digitally repositioned and was referred to our centre. On examination at our centre, about 3 h after his fall, he had tachycardia but was haemodynamically stable. Abdomen examination revealed tenderness in the lower abdomen with no peritoneal signs. There were no bruises or evidence of pelvic fracture. A rectal examination showed only blood and no mass was seen. A magnetic resonance imaging (MRI) of the abdomen was performed which picked up a tear in the rectum about 2–3 cm just above the peritoneal reflection with the omentum plugging it [Figure 1a and b]. On repeated questioning, he denied any history of rectal instrumentation or abnormal sexual activity. He had no history of constipation or rectal prolapse. He had undergone an appendectomy many years ago. He was administered broad spectrum antibiotics and taken up for a diagnostic laparoscopy during which a 3 cm transverse tear in the left anterolateral aspect of the rectum just at the peritoneal reflection with the omentum plugging it was seen with minimal contamination [Figure 2]. There were no underlying faecoliths. The omentum and pelvic cavity were irrigated with copious saline. The tear was repaired in two layers [Figure 3] using four ports, one 10 mm and three 5 mm. A covering loop sigmoid colostomy was added. He made an uneventful post-operative recovery. Eight weeks later, a rectal contrast study was done which showed no leak of contrast, and a sigmoidoscopy to rule out an underlying pathology was normal following which his colostomy was closed. Three months following the last surgery, he is doing well. He was repeatedly questioned but denied any direct trauma, in any form that could have caused the injury.

Figure 1

(a) Axial sections of magnetic resonance imaging of the abdomen showing a tear in the rectum about 2–3 cm just above the peritoneal reflection with the omentum plugging it, (b) axial section of T2 FS images showing a bulky tail of the pancreas with mild fat stranding in the tail region

Figure 2

Laparoscopic view showing the tear in the rectum at the level of the peritoneal reflection along with the omentum that was plugging it

Figure 3

Intra-operative photograph showing the repaired rectal tear

DISCUSSION

First reported by Brodie in 1827, spontaneous rupture of the rectum is rare. Usually seen in older patients, cases as young as 6 years of age have been reported.[3] In the younger patients, it is imperative to rule out a history of deliberate or accidental trauma as the cause. Although termed as spontaneous, the pathogenesis of such rupture is a sudden increase in the intra-luminal pressures which can occur as a result of blunt abdominal trauma, lifting heavy weights, straining while passing stools, sneezing, micturation and even vomiting.[4] In our case, we believe that the sudden contraction of the abdominal muscles and anal sphincters as a protective mechanism during the fall would have led to an increase in the intra-abdominal and intra-rectal pressures. At least one case of a spontaneous rupture occurring during sleep has been described.[5]

These ruptures occur in the presence of pre-disposing factors such as rectal prolapse, chronic constipation or the presence of a deep rectovesical/uterine pouch.[4] Studies have shown rectal prolapse to be associated in 60–76% of cases.[36] Our case is conspicuous by the absence of any such factors. The location of rupture in the rectum, it is almost always just proximal to the peritoneal reflection in its anterior aspect.[7] Only occasionally, a prolapse of omentum or small bowel as a presentation of rectal perforation has been reported.[14] In the presence of peritoneal signs or prolapsed bowel/omentum, no imaging is really required to clinch the diagnosis and the patient proceeds to surgery. In our case, there were no peritoneal signs, and since we did not find a prolapsed omentum, notwithstanding the findings of the previous hospital, we proceeded to do an MRI for the patient. This was also because we did not believe that a fall, so trivial, on the gluteal region could cause a rectal rupture.

Once suspected, an urgent surgery is needed and follows the principles of colorectal trauma. A laparoscopic approach to repair of rectal perforation is feasible, especially in cases which present early. One of the first reports of this approach was by Najah and Pocard in 2015.[2] The challenge in these cases would be to suture the rent which is just at the peritoneal reflection, deep in the pelvis and in a limited space. The port placement would be the same as those in rectal prolapse surgery. The site of perforation is identified and the extent of contamination assessed. The prolapsed bowel or omentum, depending on its viability, is either thoroughly cleansed or resected. The rectal tear is repaired and a biopsy of the edges is warranted if an underlying pathology is suspected. Although there are some reports that have avoided a colostomy in the absence of gross contamination,[2] a covering stoma is usually done as this would avoid the devastating pelvic sepsis in the event of a leak from the repair. There are some reports of a Hartmann's procedure being done too.[8] We believe that this may be necessary only in the presence of large tears with significant contamination or a faecal loading of the sigmoid colon proximal to the tear as it would render the diversion ineffective. Some authors suggest obliteration of the deep pouch if present to prevent recurrences.[9] There are at least two cases of recurrent ruptures reported in literature.[7] An associated rectal prolapse needs to be dealt later, possibly at the time of colostomy closure. Any other pathological condition leading to the tear needs to be investigated and treated.

CONCLUSION

Spontaneous rupture of the rectum is a rare occurrence. It can occur in younger age groups and even in the absence of significant trauma. In all such cases, one needs to diligently bring out a history of a history of rectal trauma, deliberate or otherwise. This has implications for an early diagnosis and possible psychiatric evaluation of such patients. Equally important is to rule out any underlying pathological condition. Surgical management has to be undertaken early for a favourable outcome. A laparoscopic approach is possible, especially in early cases.

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Conflicts of interest

There are no conflicts of interest.