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Massive Rectal Prolapse with Small Bowel Involvement
Image of the Month Massive Rectal Prolapse with Small Bowel Involvement WILLIAM A. HACKWORTH and ALVIN M. ZFASS Virginia Commonwealth University Health System, Division of Gastroenterology, Hepatology, and Nutrition, Richmond, Virginia
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43-year-old man with a history of alcohol abuse presented to our hospital with complaints of rectal prolapse. The prolapse had been gradually worsening over a 3-year period and was associated with fecal incontinence and wetting of undergarments. The patient had no complaints of constipation and suffered only mild discomfort during prolapse. He denied history of receptive anal intercourse, childhood abuse, or other anal trauma. His prolapse was typically elicited by straining, and could be manually reduced with some difficulty. Rectal exam revealed trace prolapse at rest and decreased anal sphincter tone. Straining produced an external mass measuring approximately 12 ⫻ 15 cm (Figure A). Colonoscopy was performed and revealed a 2 ⫻ 4 cm patch of mild erythema along the anterior rectal wall approximately 6 cm from the anal verge, without ulceration or identifiable lead point. Defecography revealed incontinence upon relaxation of the puborectalis. Approximately 14 cm of rectum was observed to prolapse. Additionally, approximately 30 cm of small bowel
prolapsed out of the anus along the anterior rectal wall (Figures B and C). Rectal prolapse is largely a disease of older women and is uncommon in young men.1 Concurrent prolapse of small bowel is exceedingly rare. Evisceration of small bowel through the rectum has been reported, likely secondary to chronic ulceration and perforation of the anterior rectal wall.2 Treatment of rectal prolapse is typically by abdominal rectopexy with bowel resection or perineal rectosigmoidectomy. Abdominal rectopexy is associated with lower recurrence rates and is typically favored in younger patients, while perineal rectosigmoidectomy is somewhat safer and is often used in elderly patients.1 References 1. Kim DS, Tsang CB, Wong WD, et al. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999; 42:460 – 466; discussion 466 – 469. 2. Keshava A, Stewart P. Education and imaging. Gastrointestinal: small bowel evisceration with chronic rectal prolapse. J Gastroenterol Hepatol 2007;22:957.
Conflicts of interest The authors disclose no conflicts. © 2010 by the AGA Institute 1542-3565/10/$36.00 doi:10.1016/j.cgh.2009.03.027 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:xxiv
A
43-year-old man with a history of alcohol abuse presented to our hospital with complaints of rectal prolapse. The prolapse had been gradually worsening over a 3-year period and was associated with fecal incontinence and wetting of undergarments. The patient had no complaints of constipation and suffered only mild discomfort during prolapse. He denied history of receptive anal intercourse, childhood abuse, or other anal trauma. His prolapse was typically elicited by straining, and could be manually reduced with some difficulty. Rectal exam revealed trace prolapse at rest and decreased anal sphincter tone. Straining produced an external mass measuring approximately 12 ⫻ 15 cm (Figure A). Colonoscopy was performed and revealed a 2 ⫻ 4 cm patch of mild erythema along the anterior rectal wall approximately 6 cm from the anal verge, without ulceration or identifiable lead point. Defecography revealed incontinence upon relaxation of the puborectalis. Approximately 14 cm of rectum was observed to prolapse. Additionally, approximately 30 cm of small bowel
prolapsed out of the anus along the anterior rectal wall (Figures B and C). Rectal prolapse is largely a disease of older women and is uncommon in young men.1 Concurrent prolapse of small bowel is exceedingly rare. Evisceration of small bowel through the rectum has been reported, likely secondary to chronic ulceration and perforation of the anterior rectal wall.2 Treatment of rectal prolapse is typically by abdominal rectopexy with bowel resection or perineal rectosigmoidectomy. Abdominal rectopexy is associated with lower recurrence rates and is typically favored in younger patients, while perineal rectosigmoidectomy is somewhat safer and is often used in elderly patients.1 References 1. Kim DS, Tsang CB, Wong WD, et al. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999; 42:460 – 466; discussion 466 – 469. 2. Keshava A, Stewart P. Education and imaging. Gastrointestinal: small bowel evisceration with chronic rectal prolapse. J Gastroenterol Hepatol 2007;22:957.
Conflicts of interest The authors disclose no conflicts. © 2010 by the AGA Institute 1542-3565/10/$36.00 doi:10.1016/j.cgh.2009.03.027 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:xxiv