Self-induced penetrating rectal perforation by foreign body: an unusual event in childhoodMammadov, Emil; Alim, Altan; Eliçevik, Mehmet; Celayir, SinanAnnals of Pediatric Surgery: January 2011 - Volume 7 - Issue 1 - p 25–26 doi: 10.1097/01.XPS.0000393087.93696.00 Case Reports Abstract Author Information Article Outline Traumatic rectal perforation is a very rare and dangerous emergency in childhood. We present a case of rectal perforation due to self-induced transanal impalement. Faculty of Cerrahpaşa Medical, Department of Pediatric Surgery, İstanbul University, İstanbul, Turkey Correspondence to Sinan Celayir, MD, Şakaci Sokak Mehmet Sayman Apt., No. 61, D-8, 34736-Kazasker, Kadiköy- İstanbul, Turkey Tel: +90 216 4106048 and +90 532 2832898; fax: +90 216 4450858; e-mail: firstname.lastname@example.org Received April 13, 2010 Accepted June 25, 2010 Abstract Introduction Case report Discussion References Back to Top | Article Outline Introduction Traumatic rectal perforation is an uncommon diagnosis in pediatric population [1–4]. Most frequent causes are traumatic, commonly following falls and rectal impalement . For the diagnosis of rectal impalement, special attention should be focused on the history of the patient and physical examination should be performed to discard sexual abuse. Therapeutic protocols are nearly the same as adult including primary repair of perforation site with fecal diversion . Attention should be paid to associated injuries of intrapelvic organs. Back to Top | Article Outline Case report A 15-year-old male patient was admitted to our clinic with complaints of sudden onset of severe abdominal pain, bilious vomiting, and rectal bleeding for 12 h. The body temperature was 40–41°C. He did not mention any type of trauma on history. Physical examination showed signs of acute abdomen and fresh blood on digital rectal examination. Pneumoperitoneum was detected on an erect plain abdominal radiograph (Fig. 1). Fig. 1 The patient proceeded to emergency explorative laparotomy. The exploration was performed by midline incision. One liter of fluid with intestinal contents was drained from the abdominal cavity. A 3×3 cm in diameter perforation site was detected on the anterior wall of the rectum at the level of peritoneal reflection (Fig. 2). There was no other associated injury in the abdomen and pelvis. The lumen of the rectum that was proximal and distal to the level of perforation appeared to be normal. The edges of the perforation site were excised and repaired primarily (Fig. 3). Protective diverting colostomy was applied. Fig. 2 Fig. 3 The patient confessed self-performed transanal impalement by a cleaning mop handle postoperatively. Pediatric psychiatry consultation diagnosed this condition as autoerotism. The recovery period was uneventful, and the patient was discharged on the seventh postoperative day. The colostomy was closed 1 month later. Back to Top | Article Outline Discussion Anorectal impalement injuries have favorable prognosis in childhood, being diagnosed early because of the traumatic background of the injury. Among these injuries, the cases of intraperitoneal perforation or multiple trauma in adjacent pelvic organs constitute real emergency, and require a more careful examination. Different approaches in the management of traumatic rectal perforations are experienced ranging from primary closure alone in early presented cases to primary closure, fecal stream diversion, and debridement. In our opinion, the mainstays of the treatment protocol are admission time, patient's general condition, and the extent of injury. In our case, the misdiagnosis of rectal impalement was due to concealment of history by the patient himself. The postoperative history taken from the patient enlightened the event. Psychiatric consultation showed slight mental retardation that needed further investigations such as IQ test. The condition was interpreted by the psychiatrist as autoerotism of adolescence, requiring conversational psychotherapy. Structures such as the bladder, uterus, and rectum lie low in the pelvis of the child and are intraperitoneal rather than intrapelvic, making children more prone to injury. Lack of external findings does not rule out rectal perforation. The workup should include endoscopy to rule out bowel perforation, vaginoscopy in girls, and cystoscopy or urography to identify urinary tract injury, especially if hematuria is present . The main complication after penetrating perineal injuries is wound infection with abscess formation and subsequently sepsis. This is why fecal diversion still stays as a mainstay of management [4,5]. Although lack in the number of cases and limited experience, anorectal impalements in childhood still have good prognosis being diagnosed and managed early [3,4]. Careful history and examination are important to exclude sexual abuse. The interventions should be performed by well-trained pediatric trauma surgeons in the setting supported with intensive care unit. Back to Top | Article Outline References1. Beiler HA, Zachariou Z, Daum R. Impalement and anorectal injuries in childhood: a retrospective study of 12 cases. J Pediatr Surg. 1998;33:1287–1291 Cited Here... | PubMed | CrossRef 2. Kim S, Linden B, Cendron M, Puder M. Pediatric anorectal impalement with bladder rupture: case report and review of the literature. J Pediatr Surg. 2006;41:E1–E3 Cited Here... | PubMed | CrossRef 3. Grisoni ER, Hahn E, Marsh E, Volsko T, Dudgeon D. Pediatric perineal impalement injuries. J Pediatr Surg. 2000;35:702–704 Cited Here... | PubMed | CrossRef 4. Jona JZ. Accidental anorectal impalement in children. Pediatr Emerg Care. 1997;13:40–43 Cited Here... | View Full Text | PubMed | CrossRef 5. Tokunaga Y, Hata K, Nishitai R, Kaganoi J, Nanbu H, Ohsumi K. Spontaneous perforation of the rectum with possible stercoral etiology: report of a case and review of the literature. Surg Today. 1998;28:937–939 Cited Here... | PubMed | CrossRef Keywords: children; foreign body; rectal perforation © 2011 Annals of Pediatric Surgery Article Outline Abstract Introduction Case report Discussion References Source Self-induced penetrating rectal perforation by foreign body: an unusual event in childhood Annals of Pediatric Surgery7(1):25-26, January 2011. Full-Size Email + Favorites Export View in Gallery Email to a Colleague Colleague's E-mail is Invalid Your Name: (optional) Your Email: Colleague's Email: Separate multiple e-mails with a (;). Message: Thought you might appreciate this item(s) I saw at Annals of Pediatric Surgery. Send a copy to your email Your message has been successfully sent to your colleague. Some error has occurred while processing your request. Please try after some time. Email to a Colleague Colleague's E-mail is Invalid Your Name: (optional) Your Email: Colleague's Email: Separate multiple e-mails with a (;). 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