抽象的
小肠从肛门脱出是直肠损伤后罕见的并发症。对于复发性直肠脱垂患者，手术干预延迟会导致直肠壁因慢性缺血而变薄，从而增加直肠破裂、小肠受累及进而发生顺行性套叠的风险。自 1827 年 Bodie 首次描述该病以来，全球报告的病例不足百例。本例患者为 78 岁男性，直肠脱垂未治疗已达 60 年。跌倒后，腹压骤增，导致直肠破裂，小肠经肛门套叠。患者紧急接受 Hartmann 手术，术后恢复良好。本例强调了对慢性直肠脱垂进行早期手术干预的必要性，以防止严重的并发症。本例也揭示了外力作用下直肠损伤的独特机制，为处理类似的复杂病例提供了宝贵的思路。
关键词： 直肠脱垂，小肠摘除术，Hartmann 手术，急诊治疗，病例报告
1 简介
直肠脱垂 (RP) 是指直肠壁部分或全层向下移位，部分或全部突出于肛门之外 ( 1 )。该病主要影响女性和老年人，女性发病率是男性的六倍。老年人，尤其是患有慢性便秘和盆底功能障碍的老年人，对 RP 的易感性更高，并且容易出现严重并发症，从而显著影响生活质量 ( 2 )。临床表现包括大便失禁、排便梗阻、直肠排空不完全和盆腔疼痛 ( 2 , 3 )。完全性直肠脱垂可能引发罕见但危及生命的后遗症，例如坏疽性坏死或穿孔 ( 4 )。
直肠脱垂（RP）常与盆底解剖和功能异常有关，例如乙状结肠延长、直肠膀胱袋或直肠子宫袋加深、肛提肌松弛、盆底筋膜无力等（ 1 ）。此外，直肠脱垂还与患者自身的营养状况、年龄、肠道炎症程度等有关（ 5 ）。手术是 RP 的首选治疗方法。RP 的手术方法很多，根据手术入路可分为经腹入路和经会阴入路（ 6 ， 7 ）。若患者未能及时手术治疗，可发展为慢性及复发性直肠脱垂，引发大便失禁、坏死性肠套叠、肠黏膜缺血、溃疡、穿孔，甚至绞窄性肠坏死等一系列并发症（ 8 ）。值得注意的是，创伤性外力（如跌倒或腹压突然升高）可进一步增加脱垂肠段损伤的风险，导致肠穿孔、腹腔感染等危重情况（ 9 ， 10 ）。
复发性直肠脱垂导致小肠破裂，经直肠脱出小肠的报道极为罕见。本病例涉及一位78岁男性患者，此前未接受过复发性直肠脱垂的手术干预，因跌倒而经肛门经破裂的直肠脱垂进行小肠脱出。通过分析其发病机制、治疗过程和手术决策，本病例为类似复杂病例的治疗提供了宝贵的思路，并引发了对老年患者家庭护理的反思。
2 病例报告
2025 年 1 月 21 日，一名 78 岁男性患者因小肠及直肠脱出肛门，伴有 3 小时出血，就诊于我院急诊。3 小时前，患者排便时出现 RP（复发性脱垂）。在尝试手法复位时，患者不慎跌倒，站立后出现腹痛、腹胀、恶心呕吐。随后，小肠及直肠脱出肛门，伴有少量出血（ Figure 1 ）。
图 1.
入院时进行经肛门小肠摘除术。
患者直肠脱垂病史60年，未曾手术干预，常采用手法复位直肠。既往无小肠脱肛史。2009年车祸致颅内出血，开颅手术后出现左下肢运动功能障碍。2018年脑梗塞，予保守治疗。2024年6月抬重物致腰椎骨折，予骨水泥强化治疗。2024年10月再次脑梗塞，继续保守治疗。
2.1 Investigations
After admission, the vital signs of the patient were relatively stable: body temperature 36.7°, pulse 107 beats/min, respiration 21 breaths/min, blood pressure 123/85 mmHg. Abdominal examination revealed positive signs of peritoneal irritation (abdominal muscle tension, tenderness, and rebound tenderness), and weakened bowel sounds.
Due to rectal prolapse, the location of the rupture can be reached by digital rectal examination. We disinfected the small intestine with diluted iodophor solution and then sent it back into the abdominal cavity through the rupture. After returning the small intestine and rectum to their normal positions in the emergency department, imaging and laboratory tests were performed to assess the patient’s general condition. Computed tomography (CT) showed multiple free gas in the abdominal cavity, with the small intestine dilated and filled with gas (Figure 2A); diffuse exudation in the abdominal and pelvic cavities with multiple effusions; thickening of the intestinal wall in the lower segment of the rectum, with intestinal images visible inside, suggesting intussusception (Figures 2B, C); the lower end of the rectum protruded outside the anus, suggesting rectal prolapse (Figures 2C, D).
FIGURE 2.
CT imaging findings. (A) The CT imaging manifestations of small intestine dilation and inflation, the red arrow indicates the dilation of the small intestine; (B) imaging manifestations of small intestine prolapse after rectal rupture and the red arrow indicates the site of rectal rupture; (C) the imaging shows that there is intussusception and rectal prolapse and the red arrow indicates the lesion site; (D) the coronal plane imaging manifestations of the patient, the red arrow indicates the location of recurrent rectal prolapse and intussusception.
2.2 Treatment
The emergency surgery was conducted by colorectal surgeons. Under general anesthesia, the patient was positioned in lithotomy for manual reduction of the small intestine. Examination of the anus and surrounding areas did not reveal any injuries or deformities. The anus was temporarily sealed intraoperatively with gauze (Figures 3A, B). Intraoperative laparotomy revealed no fecal or purulent contamination within the peritoneal cavity (Figure 3C). However, due to the bleeding after rupture and the repeated repositioning of the small intestine, infection occurred, leading to symptoms related to peritonitis. A 2-cm rectal perforation was identified on the anterior wall of the upper rectum, approximately 6 cm above the peritoneal reflection (Figure 3D). Given the patient’s advanced age, poor nutritional status, and concurrent localized peritonitis, resection and anastomosis of the damaged rectal tube is a very risky procedure. Consequently, the decision was made to perform a Hartmann procedure, which involved resection of the perforated rectal segment and creation of a colostomy (Figures 3E, F).
FIGURE 3.
The surgical process of the patient and the gross pathological specimen. (A) The condition around the anus of the patient when in the lithotomy position; (B) before the operation, the patient’s anus was blocked by gauze; (C) The condition of small intestine and abdominal cavity during the operation; (D) the location of the rectal rupture; (E) Hartmann procedure for distal colon occlusion; (F) proximal colostomy formation in Hartmann’s procedure; (G, H) Postoperative gross pathological specimen.
2.3 Outcome and follow-up
The patient underwent resection of the ruptured rectal segment approximately 8 cm long, with a breakage point visible about 2.5 cm away from the residual end on one side, measuring about 2.2 * 1 cm (Figure 3G). The gross pathological examination after the operation showed that the intestinal wall around the rupture site was very weak (Figure 3H). Under the microscope, acute and chronic inflammatory reactions of the intestinal mucosa could be seen at the breakage point, as well as full-thickness bleeding of the intestinal wall, with some mucosa detaching and necrotizing accompanied by acute inflammatory exudation, which was consistent with the pathological manifestations of intestinal rupture. The patient recovered normally after the operation and had no other complications. Seven days later, he was discharged smoothly. Whether to undergo colostomy reversal surgery will be evaluated based on the patient’s physical condition. A timeline of the patient’s disease progression is shown in Figure 4A. Figure 4B shows the path of evisceration of the small intestine.
FIGURE 4.
(A) A timeline of the patient’s disease progression. (B) The illustration to show the path of evisceration of the small intestine.
From the perspective of the patient and his family, the emergency surgery was very satisfactory. Besides, in the home care, for patients with rectal prolapse, early surgical intervention is necessary.
3 Discussion
Rectal prolapse encompasses various types, including complete and incomplete prolapse, as well as external and internal prolapse. In cases of incomplete prolapse, also referred to as mucosal prolapse, only the rectal mucosa is displaced downward. Complete prolapse occurs when the entire rectal wall descends. Internal prolapse refers to the descent of the rectal wall within the anorectal cavity, while external RP involves the protrusion of the rectal wall outside the anus (11). Complete rectal prolapse can lead to numerous complications, such as damage to the rectum and surrounding structures, incarceration, perforation, strangulation. Abdulgader et al. reported a case of incarcerated rectal prolapse (12). This study is a special case of rectal prolapse complicated with rupture and perforation.
Transanal intestinal evisceration is a rare complication of chronic RP. Chronic prolapse can lead to ischemia of the anterior rectal wall, and repeated episodes of ischemia over time result in thinning of this region. In such a compromised state, a sudden and significant increase in intra-abdominal pressure can cause perforation at the weakened area of the rectum, allowing the small intestine to protrude through the damaged rectal wall into the anus (10). This condition was first described by Brodie in 1827 (13). Over the subsequent two centuries, approximately 100 cases of transanal small intestinal prolapse following rectosigmoid rupture have been reported globally. Most patients presented with a history of recurrent rectal prolapse and had not undergone timely surgical intervention during the early stages of their condition. Upon presentation, these patients often exhibited urgent and life-threatening conditions, leading to a high mortality rate. Historically, patients with rectal rupture and transanal small intestinal evisceration almost invariably experienced factors that increased intra-abdominal pressure, such as defecation, vomiting, heavy lifting, or manual reduction after prolapse (14). The development of colostomy and Hartmann surgery has significantly improved outcomes; from 1979 to 2021, the mortality rate for patients with rectal rupture and transanal small intestinal prolapse decreased from 63 to 13%. Previous case analyses have demonstrated that patients who only received primary repair of the perforation had a mortality rate as high as 80% (15). Combining rectal tear repair with colostomy reduced the mortality rate to 23% (14).
The evolution of the patient’s condition and the process of diagnosis and treatment in this case involve multiple critical clinical issues. Untreated RP for a long time (60 years) represents a potential risk. The recurrent episodes of RP lead to degeneration of the intestinal wall muscle layer, thereby increasing the risk of perforation. Getting up forcefully after falling down, which caused a sudden increase in intra-abdominal pressure and mechanical traction, directly resulted in rectal rupture and small bowel prolapse, indicating that trauma is an important cause of acute rectal injury. In this case, considering the patient’s advanced age, malnutrition and local peritonitis which might increase the risk of anastomotic leakage, the Hartmann procedure (partial rectal resection with colostomy) was chosen.
The advantages of the Hartmann procedure include complete removal of the source of infection, avoidance of anastomotic complications, and preservation of the possibility for future restoration of intestinal continuity. The primary repair is applicable to patients without peritoneal contamination and with no massive bleeding. It can directly repair the perforation site. However, for patients with chronic rectal prolapse, it is prone to increase the risk of recurrence (10). Postoperative gross pathological findings revealed full-thickness bleeding and mucosal necrosis of the intestinal wall, consistent with acute perforation. The smooth postoperative recovery confirms the effectiveness of the emergency surgical strategy, but whether to perform colostomy reversal will depend on a comprehensive assessment of the patient’s neurological function, nutritional status, and surgical tolerance.
This case suggests that for patients with long-term rectal prolapse, surgical intervention should be carried out as early as possible to prevent the occurrence of serious complications. At the same time, when dealing with such complex cases in the emergency department, an appropriate surgical method should be selected based on the specific condition of the patient. This Supplementary material presents the information list of the CARE case report for this study.
Funding Statement
The author(s) declare that financial support was received for the research and/or publication of this article. This research is supported by Medical Science Research Program of Hebei Province, No. 20250060.
Data availability statement
The original contributions presented in this study are included in this article/Supplementary material, further inquiries can be directed to the corresponding author.
Ethics statement
The studies involving humans were approved by Ethics Committee of the Second Hospital of Hebei Medical University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
Author contributions
ZT: Resources, Writing – original draft. XM: Writing – original draft, Writing – review and editing. ML: Writing – review and editing. HR: Writing – review and editing. GZ: Resources, Writing – review and editing. YZ: Funding acquisition, Writing – review and editing.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmed.2025.1581332/full#supplementary-material
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Associated Data
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Supplementary Materials
Data Availability Statement
The original contributions presented in this study are included in this article/Supplementary material, further inquiries can be directed to the corresponding author.