Thiersch Repair of a Spontaneous Rupture of Rectal Prolapse with Evisceration of Small Bowel Through Anus - A Case Report

Abstract

Spontaneous rupture of colon or rectum is a rare event. Protrusion of several loops of small bowel through the anal orifice is a bizarre condition which has only rarely been reported in the literature. We report the first case where Thiersch repair was used to manage spontaneous perforation of rectal prolapse and provided a successful outcome.

Spontaneous rupture of colon or rectum is a rare event.^1–4 Protrusion of several loops of small bowel through the anal orifice is a bizarre condition which has only rarely been reported in literature. Since Benjamin Brodie reported the earliest case in 1827, only 65 cases have been reported in the literature till now. It is associated with spontaneous rupture of the distal sigmoid or rectum. This may be caused by a sudden increase in intra-abdominal pressure. Erosion of the prolapsed segment may play a part. The majority of the patients have had a past history of rectal prolapse.

Case report

A 90-year-old woman presented with prolapsed loops of small bowel protruding through the anus, following defaecation. She had a past history of rectal prolapse for 30 years but had never been to a surgeon for treatment. She was otherwise fit and well and not on any medication. The event occurred 2 h prior to admission.

On examination, she was afebrile with stable vital signs. She was extremely frail. Abdomen was soft and non-tender. Examination of perineum revealed several loops of small bowel protruding from the anus. The serosal surface appeared pink with visible peristalsis. All her initial blood investigations were within normal limits.

The patient was taken to theatre, where she was prepared and placed in the Lloyd-Davies position. The prolapsed small bowel was repositioned through the rectal tear after copious irrigation and cleansing. Rectal tear was repaired with PDS trans-anally and Thiersch stitching was applied for the rectal prolapse (Figs 1–4). A trephine sigmoid colostomy was performed to protect the integrity of the rectal suture line. The postoperative period was uneventful.

Figure 1.

Protrusion of several loops of small bowel through the anal orifice

Figure 4.

Figure 2.

Figure 3.

The patient was reviewed in clinic 2 months and 6 months after the operation and noted to have no complications.

Discussion

In most patients with spontaneous rectal perforation, rectal prolapse was an associated clinical condition. Wrobleski and Dailey⁵ reported rectal prolapse in 22 out of 30 cases (73%) Czerniak et al.⁶ reported rectal prolapse in 18 out of 27 cases (67%).

This rare complication of procidentia in our case was treated by suture of tear in the rectum, with a defunctioning colostomy and a Thiersch repair, without resection of the viable herniated small intestine.

The alternative method of a laparotomy would have been a considerable physiological insult on the frail lady. Although Thiersch repair is not commonly used now-adays, it proved to be a quick and effective way to manage rectal prolapse in our particular case.

In elderly patients presenting in an emergency situation as encountered in our case, Thiersch repair is an option to be considered. We would also like to report that this is the first case where Thiersch repair was used to manage spontaneous perforation of rectal prolapse and it has provided a successful outcome.