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 and ]. 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 []. There were no underlying faecoliths. The omentum and pelvic cavity were irrigated with copious saline. The tear was repaired in two layers [] 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.
We present the case of an 81-year-old woman without interesting medical precedents excepting a moderated cognitive deterioration (with partial dependence for activities of daily living). She was taken to the hospital by her relatives after they found her in the bathroom presenting with intestinal loops exiting through her anus. The presence of a rectal prolapse was not among her precedents ().\nOn the first exploration, we recognized an abdominal excavation, which was painless on palpation, and we observed many small intestine loops with a congestive aspect exiting through the anus. When the patient arrived, she was hypotensive and tachycardic. After the first resuscitation attempt, an urgent blood test was requested, and the results showed albumin, 3; C-reactive protein, 47.3 mg/dL; and 19,700 leukocytes with neutrophilia, indicating an urgent need for surgery. The patient was taken to the operating room less than two hours after the beginning of the symptoms, and during the surgery, her hemodynamic condition remained the same.\nFor the surgery, the patient was placed in a modified lithotomy position, and two areas (abdominal and perineal) were prepared. After checking the difficulty of reducing the intestine exclusively through the anus, we performed an exploratory laparotomy, which revealed the absence of small intestine loops in the cavity; these had been moved to the pelvis and this was causing an important traction of the mesentery root. As a result, a manual reduction of the loops to the cavity through intraperitoneal traction was done; this was controlled from the perineal field. After the reduction had been completed, a 3 to 4 cm lineal craniocaudal perforation in the antimesenteric portion of the upper rectum was objectified (RIS II/AAC III). An important flaccidity of the entire pelvic musculature which contained a large rectovaginal pouch was observed, which resulted in both the superior rectum and the peritoneal reflection leaning on the pelvic floor (). The peritoneal cavity was abundantly washed with hot saline, and after some minutes, the loops initiated a visible peristalsis and took on a normal coloration. Later, the superior rectum and the sigmoid colon were dissected until the promontory, and an anterior resection of the rectum and a terminal colostomy in the left iliac region (Hartmann's procedure) were performed ().\nLater, the patient's relatives told us that she had difficulties defecating and had frequently manipulate herself to extract her feces. The patient was admitted to the intensive care unit for 3 days where she remained hemodynamically stable and her ventilatory support was ceased without incidence. She had a slow recovery, and on the 6th day tolerated oral intake well. She was discharged after 13 days, and two months later remained asymptomatic.