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.
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.