2023-07-18 16:09:11
To remember
Contrary to the frequent self-diagnosis of lay people in medicine, an anorectal “tissue prolapse” is not always a hemorrhoid. The anamnesis of a perineal prolapse should therefore in principle be followed by a careful clinical examination and possibly an examination with the aid of devices, in order to be able to evaluate unusual findings, emphasize the Hamburg surgeons around Dr. Frederick JS Arndt (Clinic for General, Visceral and Tumor Surgery, Albertinen Hospital) with reference to the medical history of an 87-year-old woman.
The patient and her story
The patient presented to the outpatient surgery department with perineal hemorrhage and unexplained perineal tissue prolapse. The 87-year-old woman herself had not reported any recent complaints, including abdominal or perianal pain. She denied having recently undergone perianal measures (e.g. enemas or colonoscopies), or abdominal or (peri)anal operations.
Results and diagnosis
Patient in stable general and nutritional condition corresponding to her age. Local diagnosis: soft tissue prolapse, painless on pressure, resembling a loop in the small intestine. Little blood and stool at fingertip. Decreased sphincter pressure with age. Another unremarkable clinical examination. The suspected diagnosis was as follows: perineal prolapse of the small intestine of undetermined origin. Computed tomography (CT) of the abdomen: in the lumen of the rectum, loop of the small intestine via a perforation in the ventral wall of the upper rectum. No free air or free liquid. Colonoscopy: intraluminal loop of small intestine with subacute circulatory disturbance, rectum essentially unremarkable.
Treatment and evolution
According to the authors, a laparoscopy confirmed that an ileal loop had penetrated the anterior wall of the upper rectum. After reduction of the loop of the small intestine, it quickly recovered, so that no resection of the small intestine was necessary. Histologically, there was no evidence of dysplasia or malignancy after resection of the rectosigmoid junction. The patient made a rapid physical recovery from the operation and was able to leave the hospital after undergoing geriatric rehabilitation and regaining her preoperative stable general condition.
Discussion
According to the authors, this medical history shows an unusual form of perineal prolapse; it also clearly shows that the clinical indication for “tissue prolapse” is not always hemorrhoids, a pedunculated polyp or a rectal prolapse. Furthermore, the benign course of the 87-year-old patient’s case is unusual.
Another prolapse in this region, namely a rectal prolapse, is of course not unusual. Rectal prolapse affects women more often than men (9:1) and occurs mainly from the age of 65. Patients with rectal prolapse complain of sharp anal pain accompanied by disorders of constipation and hematochezia. If incarcerated, the prolapsed part may be underperfused and become necrotic. This clinical picture is very rare, but it is life-threatening. Hemorrhoids can also be prolonged. Depending on the stage of the so-called hemorrhoidal disease, the hemorrhoidal nodules that have formed spontaneously slide back or have to be reduced.
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