Transanal Evisceration of Small Bowel about One Case at the University Hospital Yalgado Ouédraogo of Ouagadougou

Introduction: Transanal evisceration of small bowel is an extremely rare condition that can occur spontaneously or after trauma. Objective: To report a case of Transanal evisceration of small bowel to describe the circumstances of occurrence and our therapeutic attitude. Observation: An 80year-old female patient was received at the visceral Emergency of University Hospital Yalgado Ouédraogo for the outcome of the small intestine by the anus with the waning of a defecation effort. The physical examination of the patient accustomed to evacuation purgation noted, eviscerated the small bowel through the anus, edematous but viable. The preoperative laboratory tests were normal. In emergency, under general anesthesia, a laparotomy was possible to objectify the incarceration of intestinal loops through linear perforation of 5 cenimeter from the anterior surface of the rectosigmoid hinge. We conducted an ileo-ileal resection anastomosis, a suture rectosigmoid breach and anal extraction of small bowel incarcerated measuring 200 centimeter. The evolution was simple. Conclusion: The weakening of the rectal mucosa by repeated purges has certainly been the contributory factor. The surgical treatment must be precocious to avoid extensive intestinal resection.


Introduction
The transanal evisceration of small bowel is an extremely rare disease [1].It can occur spontaneously or following abdominal trauma.The first description was made in 1827 by Sir Benjamin Brodie [1].Since then several cases have been reported worldwide and recently in Senegal in 2011 [2], in India in 2013 [3], in Spain in 2014 [4].We report our first case of transanal evisceration of small bowel in order to describe the circumstances of occurrence and our therapeutic approach.We have obtained the informed consent of the patient to the writing of this observation.

Case Report
An 80-year-old female patient presented on 19-01-2015 to emergency of university hospital Yalgado Ouedraogo with small intestine externalized through the anus for 24 hours.She reported a chronic constipation and he was accustomed to evacuation purges.The externalizing of intestinal loops occurred after pushing effort during defecation.This intestinal loops eviscerated through anus were pink; edematous and covered with false membranes and telluric debris (Figure 1).The rectal mucosa was smooth and presented a perforation of the anterior surface of its upper portion.The diagnosis of transanal evisceration of small intestine was retained.The preoperative laboratory tests were normal.In emergency under general anesthesia a laparotomy was performed.The exploration has noted a loop of small bowel incarcerated through a longitudinal perforation in the anterior face of rectosigmoid.This perforation measured centimeter, with soft and regular edges (Figure 2).There was no mesenteric lymphnode or colic tumor.The abdominal cavity was clean.Eviscerated bowel portion was located 5 centimeter from ileocecal junction and 300 centimeter from the angle of Treitz.We performed, a small bowel resection followed by an immediate end-to-end anastomosis, a suture of the rectosigmoid perforation and drainage of Douglas pouch.The eviscerated intestinal loops were removed by rectal route and measured 200 centimeter.The outcome was simple.She was seen at 30 and 90th days in postoperative control.There were no complaints and clinical examination was normal.

Discussion
The transanal evisceration of small bowel is extremely rare [1].The first description was made in 1827 by Sir Benjamin Brodie [1].Until this period, very few cases have been described sporadically in the world and there are less than 70 cases reported in the literature [4].Our case is the first observation in Burkina Faso.The mystery that raises our presentation as in other authors remains the etiology of the perforation of the rectosigmoid [5] [6].The transanal evisceration of small bowel may be secondary to a traumatic perforation of rectosigmoid or as part of an abdominal contusion as reported by Bâ and collaborators [2] or following an impalement [7] [8] or  a sexual assault in the child [8].In our case, as in other cases, the transanal evisceration had occurred following a spontaneous recto-sigmoid perforation [6].In this case some etiologies have been implicated, such as colorectal cancer, diverticular disease or ulcerative colitis [5].The repeated evacuations purges in our patient were certainly a factor of embrittlement of the rectosigmoid wall, by corrosive effect.In addition, the sharp increase into the rectum and the abdomen pressure during the efforts pushed of defecation has certainly favored the longitudinal perforation of the anterior surface of the rectosigmoid wall as in others authors [5].Hysterectomy and rectal prolapse were reported as factors weakening anterior wall of rectosigmoid [5].In our case, the evisceration occurred in people aged over 60 years like that most cases published [1] [6].Advanced age would be a risk factor for spontaneous transanal evisceration.On the clinical plan, the diagnosis is made at a patient's presenting the intestinal handles outside the anus with a flat belly or of normal volume.In case of vascular lesions, a haemoperitoneum with a state of hemorrhagic shock can be observed like that was the case at BA and collaborators [2].Exceptionally a generalized acute peritonitis can be associated in case of intestinal necrosis or by defilement of the abdominal cavity by saddles of the perforation of the sigmoid colon.The treatment is not standardized.It must be early and effective to prevent an extended intestinal necrosis that requires making a great sacrifice of intestine.The two-stage surgery including suture perforation with stoma (ileum or colon) followed by a delayed recovery of digestive continuity was the attitude adopted in most of the cases [3].In our patient we performed a one stage surgery because of the good condition of the patient, a clean abdominal cavity and the stoma refusal of the older people in our context.In all cases the surgical treatment obeyed the principles of digestive surgery.The prognosis of this disease is generally favorable as in our case and in several studies [3]- [5].

Conclusion
The transanal evisceration by colorectal spontaneous rupture is rare.The etiology is multifactorial.The weakening of the rectal wall by repeated purges evacuation has certainly been the contributory factor in our case.The surgical treatment must be early to avoid extended intestinal resections.It is therefore necessary to raise awareness about the risks of purges evacuations.

Figure 1 .
Figure 1.Small intestine loops eviscerated through the anus.

Figure 2 .
Figure 2. Longitudinal perforation of the anterior surface of rectosigmoid hinge.