Evisceration of small bowel through spontaneous perforation
A 25-year-old housewife was brought to the emergency room of our hospital early in the morning, complaining of abdominal pain and prolapse of bowel loops per rectum, following defecation 3 hours ago. While having a history of a short period of rectal bleeding two years back during pregnancy, she denied any history of rectal prolapse or rectal trauma/penetration. Her drug history, family history, and psychosocial history were unremarkable.

On physical examination, the patient was hemodynamically stable but looked terrified. Her pulse rate was 95/min and blood pressure 110/75 mmHg. The abdomen was soft, but tender on deep palpation without rebound tenderness. About 50 cm of purple-colored small bowel loops were extruding from the anus. On rectal examination, the rectum was wide and filled with small bowel loops and serous fluid resembling intraperitoneal fluid, indicating rectal perforation. The bowel loops were washed with warm saline and gently reduced to avoid further ischemia. A tampon was placed to prevent re-prolapse of bowel loops while patient was being prepared for laparotomy. The diagnosis of rectal perforation was made, with suspicion of rectal trauma/penetration; however, the patient denied any rectal trauma/penetration.

The patient was prepared for emergency surgery. Laparotomy was done through lower midline incision by the surgery team (A consultant surgeon, a specialist surgeon and a junior resident). The peritoneal cavity was clean with no sign of blood or contamination. About 100 cm of small bowel loops nearly 60 cm away from the ileo-cecal valve had entered the rectum through a 7 cm longitudinal tear on anterior aspect of intraperitoneal part of the rectum. The bowel loops were gently recovered from within the rectum; they were congestive and edematous, but viable. The laceration was primarily repaired in two layers and a protecting colostomy (Hartmann's) was created. The abdomen was closed in usual way. Parenteral antibiotics were given for 5 days. Postoperatively, the patient's condition progressively improved, and she was discharged on the 7th postoperative day in good condition. Colostomy was successfully reversed after 3 months.