A 73-year-old otherwise healthy female presented to the emergency treatment unit with sudden worsening of rectal procidentia (rectal prolapse) and pain for 3 h after straining at defecation. She had a history of reducible complete rectal prolapse for 4 years, for which she did not seek treatment. She had three uncomplicated vaginal deliveries in the past. On examination, she was found to have evisceration of the small bowel through the anus rather than a rectal prolapse, without any macroscopic evidence of strangulation (). There was associated uterovaginal prolapse and perineal descent suggestive of pelvic floor dysfunction. She was hemodynamically stable with normal blood pressure and heart rate. Her biochemical investigations including serum lactate were all normal. Emergency laparotomy was performed and the small bowel was reduced into the abdomen with ease. She was found to have a linear tear, 6 cm from the anal verge on the anterior wall of the middle part of the rectum without any macroscopic evidence of ischemia or neoplasm (). The reduced small bowel was normal in appearance with good peristalsis. Primary repair of the rectal defect was carried out after obtaining a biopsy from the rectal tear and a proximal defunctioning ileostomy was created. Histological examination of the rectal biopsy was unremarkable. She was managed in the intensive care unit for 2 days post-operatively and had an uneventful recovery. The patient was discharged on the fifth post-operative day.
A 14 years old male was admitted with the chief complaint of acute lower abdominal pain which started suddenly after he passed stools. The abdomen was tender on deep palpation in the left iliac fossa and bowel sounds were sluggish. However, on per rectal examination gut loops were felt in the anal canal and finger was stained with blood thereby making intussusception the most probable diagnosis. Basic hematological and radiological investigations were normal. Patient was taken to the operation theatre for laparotomy. A lump was felt in the left iliac fossa once the patient was anaesthetized for surgery. Peroperative findings revealed a distended and a tubular sigmoid colon (intussusception like appearance) and twisting of ileal loops around the sigmoid colon simulating ileo-sigmoid knotting. On further mobilization and gentle traction on the ileal loops gangrenous segment of ileum became evident till it finally emerged out from a longitudinal perforation (approximately15mm) in the anterior wall of rectum just above the peritoneal reflection () thereby stunning the entire surgical team. No contamination of peritoneal cavity was noticed. Gangrenous segment of ileum was resected and primary anastomosis was done. Rectal tear was closed primarily in single layer after taking the biopsy from the whole edge which revealed non specific inflammation. On repeated questioning in postoperative period patient denied any history suggestive of constipation, rectal prolapse, trauma, weight lifting, rectal instrumentation or homosexual activity; however intermittent straining at stools was present. Postoperative period remained uneventful. Barium enema and colonoscopic examination in post operative follow up period were normal.