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.
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.