Management of Spontaneous Rectal Perforation at Up-Coming Medical College Hospital : A Rare Occurrence

Spontaneous perforation of large bowel compare to small bowel is very uncommon and among them “spontaneous rectal perforation” is very rare cause of acute abdomen in surgical practice. The presentation of such entity is similar to any other cause of peritonitis & pre-operatively definite diagnosis remain a diagnostic dilemma and require an emergency surgical intervention to have the best outcome. We report a case of a 83 years male presented to our Emergency Department referred from B. P. Koirala Institute of Health Sciences with feature suggestive of peritonitis, hollow viscous perforation with evidence of free air under right dome of diaphragm in chest X-ray PA view. An emergency exploratory laparotomy was performed with provisional diagnosis of duodenal ulcer perforation as being commonest in this region with differential diagnosis of appendicular perforation or small bowel perforation with peritonitis. But on exploration no perforation was found in duodenum, small bowel, appendix and large bowel etc. Lastly with much difficulty the rectal perforation could be located while removing the plaques adhered to the rectal wall. Seeing such cases a surgeon should be aware of the possibility of this fatal disease despite rare incidence. It is very important to recognize such condition at an early stage because it carries high mortality if surgical intervention is not done at early stage. Intra-operatively too a thorough search should be made towards rectum if perforation is not found easily at other sites. Hence the better prognosis is with early surgical intervention; worst the prognosis with late intervention. Birat Journal of Health Sciences 2016 1(1): 87-90


INTRODUCTION
Hollow viscous perforation is very common entity in surgical practice leading to acute abdomen.Usually the rectal perforation occurs in cases of pre-existing pathology such as trauma, iatrogenic injury eg.During colonoscopy, however spontaneous rectal perforation is 1 very extremly rare.There are no specific clinical manifestations of such disease and it usually leads to severe peritonitis in absence of sign and symptoms by the time diagnosis is made.Hence, a surgeon should be aware of such condition and must have high suspicion of index for diagnosing such cases and early surgical exploration is required to have a good outcome and to reduce mortality rate.We report a case of severe peritonitis due to spontaneous rectal perforation which was successfully managed surgically and discharged with th functioning status loop colostomy on 8 post-operative day.Patient was brought back after 20 days in Emergency with pus discharge from main wound and drain site with status functioning colostomy.Patient was examined and found to have burst abdomen with a cavity on right paracolic gutter so a corrugated drain was kept through right drain site and interrupted suture applied to the main wound.Patient was discharged after two days with advice: daily dressing, high protein high calories diet and care of the colostomy with regular follow up in OPD.On follow up after two months, patient was well tolerating orally and normal functioning colostomy and well wound healed.Patient was advised to report to SOPD for closure of loop colostomy after three months.initial resuscitation.Intra-operatively Guss of air and about 1000ml of faeco-purulent, foul smelling thick fluid was found spread all over peritoneal cavity mainly in the pelvis.A solitary perforation of approximately 0.5cms diameter with healthy margins was identified in anterior wall of the rectum about 20 cms from anal verge and about 12 cms proximal to peritoneal reflection.There was no diverticular diseases of the colon, Sigmoid colon was loaded with fecal matter.A simple closure of the perforation followed by a diversion transverse loop colostomy was performed after thorough irrigation of the peritoneal cavity.No biopsy was taken from the perforation site for histopathlogical examination.A tube drain kept in the pelvis.Abdomen closed with vicryl no 1 as mass closure and skin closed with ethilon 2/0 interrupted.
On table maturation of the colostomy was performed and non-adhesive dressing applied.The post-operative period was uneventful.Patient was managed in ICU for two days and then shifted to the general surgical ward and discharged on th 8 post-operative day.
Patient was brought back after 20 days in Emergency with pus discharge from main wound and drain site with status normal functioning colostomy.Patient was examined and found to have burst abdomen with a cavity on right para-colic gutter.So a corrugated drain was kept through right drain site and interrupted suture applied to the main wound.Patient was discharged after two days with advice: daily dressing, high protein high calories diet and care of the colostomy with regular follow up in OPD.On follow up after two months, patient was well tolerating orally and normal functioning colostomy and wound was well healed (Figure 3, 4).Patient was advised to report to SOPD for closure of loop colostomy after three months.

DISCUSSION
The incidence of spontaneous perforation of sigmoid colon or rectum is very rare.It does occur in all age groups, the youngest reported case being six years old and the oldest 2 ninety six years old.The perforation is often associated with intra-luminal pressure during defection with a pre-existing pathology such as diverticulitis, colitis, ulceration, malignancy, irradiation, adhesions or as a consequence of iatrogenic 1 injuries and blunt trauma abdomen.Chronic straining due to pre-existing disease causes progressive deepening of recto-vesical and recto-uterine pouches leading to thinning of rectal wall.Various theories have been postulated in an effort to explain the mechanism of spontaneous rectal perforation.Among them the most prevailing are: 1. Intramural hematoma formation resulting in dissection and weakening of the rectal wall.
2. Congenital anal dysplasia coexisting with a weakened area of rectal wall.delayed treatment, the mortality rate is over 60% .
Though spontaneous rectal perforation is very rare, surgeons working at periphery with limited resources should have high suspicious index to diagnose such case to have early diagnosis CONCLUSION so that at earliest surgical intervention performed to have best outcome.Rectal perforation is one of the important causes of acute abdomen and should always be kept in mind to suspect when a patient with chronic constipation presents with severe abdominal pain and absence of feature of peritonitis.The mortality rate for this condition is very high, although the incidence is very low and timely intervention can save the life in most cases.

Figure 1 :Figure 2 :
Figure 1 : CXR showing free air under right dome of diaphragm

3 .
Progressive deepening of the pouch of Douglas in combination with sudden increase of intra-abdominal 3 pressure could cause rupture of the rectum.The perforation occurs almost always in the distal part of the colon because of the physiological characteristics of rectosigmoid colon such as lower water content of the stool, relatively poor blood supply and high pressure due to the 4 narrowed intra-luminal diameter and it involves the anterior wall of the rectum just proximal to the peritoneal reflection at 4 the anti-mesenteric border of the recto-sigmoid junction.In most cases, it presents with features of diffuse peritonitis and X-ray chest shows free air under right dome of diaphragm.The treatment of this entity requires urgent surgical exploration with closure of the perforation and proximal