|Year : 2021 | Volume
| Issue : 4 | Page : 253-255
Transanal small bowel evisceration in a 3-year-old victim of motor vehicle accident
Minakshi Bhosale, Ameya Sangle, Ganesh Bhat, Praveen Dambal
Department of Pediatric Surgery, B J Government Medical College, Pune, Maharashtra, India
|Date of Submission||02-May-2020|
|Date of Decision||01-Jun-2020|
|Date of Acceptance||23-Aug-2020|
|Date of Web Publication||12-Jul-2021|
Dr. Minakshi Bhosale
G/101, Sudarshan Apartments, Behind Spencer's Daily, Karvenagar, Pune - 411 052, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Although motor vehicle accidents (MVAs) in children are common, pediatric rectal perforations secondary to MVAs leading to transanal evisceration of the small bowel are very rare. Herniation of bowel through breach in the rectal wall seen eviscerating through the anus is a surgical emergency requiring laparotomy and necessary surgical procedure. We report case of a 3-year-old boy, victim of run-over MVA accident, presenting with bilateral fracture shaft femur, fracture of the left humerus, and transanal small bowel evisceration. About 30–40 cm long, gangrenous, small bowel loop was hanging outside the anal canal. Two consecutive surgeries were performed to manage this unusual and complex case with an excellent outcome. This report is presented for an extremely rare presentation of MVA injury in a child.
Keywords: Child, motor vehicle accident injuries, rectal perforation, strangulation, transanal small bowel evisceration
|How to cite this article:|
Bhosale M, Sangle A, Bhat G, Dambal P. Transanal small bowel evisceration in a 3-year-old victim of motor vehicle accident. J Indian Assoc Pediatr Surg 2021;26:253-5
|How to cite this URL:|
Bhosale M, Sangle A, Bhat G, Dambal P. Transanal small bowel evisceration in a 3-year-old victim of motor vehicle accident. J Indian Assoc Pediatr Surg [serial online] 2021 [cited 2021 Jul 30];26:253-5. Available from: https://www.jiaps.com/text.asp?2021/26/4/253/321083
| Introduction|| |
Less than 100 cases of transanal small bowel evisceration have been reported in the English literature since the first recorded case. Most of the cases reported involve elderly population with preexisting constipation or rectal prolapse. There are <10 reports of motor vehicle accident (MVA) injuries causing rectal perforation and transanal small bowel evisceration in a child.
| Case Report|| |
A 3-year-old boy was brought to the casualty with a small bowel loop hanging outside the anus. He had sustained this injury and evisceration along with long bone injuries because of run-over by a two-wheeler, 4 h ago. On examination, he was conscious, oriented, pale, and dehydrated. Heart rate was 120/min, blood pressure was 90/60 mmHg, and respiratory rate was 40/min. He had laceration over the left occipital region and left popliteal fossa and multiple abrasions on the abdomen, face, and extremities. The abdomen was tender and guarded. A 30–40 cm long, gangrenous small bowel loop was seen eviscerating [Figure 1]. The chest, spine, and genitals were normal. Digital rectal examination was not done. Investigations showed hemoglobin level of 8 g%, white blood cell count of 15,000/mm3, blood urea nitrogen of 28 mg/dL, and normal serum electrolytes. X-rays showed bilateral midshaft femur fracture and midshaft fracture of the left humerus. Ultrasonography and computed tomography (CT) abdomen were suggestive of splenic contusion. Chest X-ray and CT brain were normal. After fluid resuscitation and hemodynamic stabilization, he was taken up in the operation theater under anesthesia. Vitality of the eviscerated bowel was rechecked. The abdomen was explored through supraumbilical transverse incision after bladder catheterization. The liver, spleen, and kidneys were normal. There was a longitudinal tear of the mesentery, and the denuded small bowel loop was seen herniating through the rectal defect. Edges of the bowel loop seen from the abdomen were dusky [Figure 2]a. There was another 2cm antimesenteric perforation distal to the excised bowel edge, which was closed using 4-0 polyglycolic acid. To avoid contamination because of the eviscerated gangrenous bowel, intestinal clamps were applied just above the herniating segment, the bowel was divided beyond the clamps, and the herniated bowel loop was pulled out from the anal canal. It is then, the anterior rectal wall defect could be well identified. It was a large, 1.5cm, full-thickness, anterior rectal perforation below the peritoneal reflection [Figure 2]b. Rectal perforation was closed using 3-0 polyglycolic acid, as a single layer using interrupted sutures. Peritoneal lavage was given. Ileostomy and mucus fistula were brought out through the same incision. 200 cc blood transfusion was given.
|Figure 2: (a) Intraoperative photograph showing the denuded, dusky eviscerated bowel (b) 1.5cm full-thickness, anterior rectal perforation just below the peritoneal reflection|
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Intravenous Fortum, Amikacin, and Metrogyl were given for 10 days. Oral feeds were started since postoperative day 5. He also received Aminodrip transfusion (5%) in view of poor nutritional status. Orthopedic reference was made for bilateral fracture femur and fracture of the left humerus, which were managed conservatively. The postoperative course was uneventful. The child was discharged after 1 month on distal loop washouts. Ileostomy closure was done 3 months later after ruling out stricture of the anorectum. Presently, at a follow-up of 1 year, the child is asymptomatic, thriving well, and has a weight gain of 4 kg. His wound and fractures have healed well. His fecal continence is normal. He is able to walk on his own after dedicated physiotherapy sessions.
| Discussion|| |
Barotrauma, blunt abdominal trauma, and iatrogenic injuries cause trauma-induced evisceration of small bowel. Blunt abdominal trauma is common among the three. Sudden sharp rise of intra-abdominal pressure at the time of impact by severe blunt abdominal trauma leads to rupture of the rectum. The resultant perforation is usually located on anterior rectal wall near the peritoneal reflection and may be transverse or longitudinal., Rupture of the rectal wall is followed immediately by evisceration of small intestine through the rent. If pressure is sustained over a long period of time, more loops traverse through the perforation. The sealing effect of the prolapsing loops of intestine limits peritonitis. However, disproportion in size of the rectal perforation and that of the prolapsing loop, coupled with tonic anal sphincter contractions can lead to strangulation of the eviscerated bowel. These children require prompt resuscitation, exclusion of other injuries, and emergency laparotomy. Depending on the viability of the eviscerated bowel, presence of contamination, time elapsed after injury, and general condition of the patient, resection anastomosis is done or stomas are created. Bowel continuity is established 8–12 weeks later.
References of cases of transanal small bowel evisceration caused by blunt abdominal trauma in children, managed by other authors, are detailed in [Table 1] to highlight the diversity of injuries sustained.,,,,,,,, It also stresses the need to undertake an individualized approach, while managing these cases. Our child survived in spite of low reserves and bilateral multiple fracture injuries because of optimum preoperative resuscitation, timely intervention, staged surgical procedure, use of higher antibiotics, and nutritional support in the postoperative period.
|Table 1: Details of cases of transanal small bowel evisceration caused by blunt abdominal trauma in children|
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With an increasing number of MVAs, the morbidity and mortality for riders as well as pedestrians is going to rise. Awareness to prevent these injuries, transportation and resuscitation within the golden hour, strengthening trauma care infrastructure, timely intervention, building trained surgical teams, and availability of blood and blood products can be lifesaving. Investing in and strengthening of these aspects is the need of the hour.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents have given their consent for his images and other clinical information to be reported in the journal. The parents understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]