Rectal prolapse
The rectum protrude outside the anus.Age incidence: from infant to old age are common, commenst age is infant and old age.
Aetiology
In infants
Due to the as-yet undeveloped sacral curve.
Reduced resting anal tone, which offers diminished support to the mucosal lining of the anal canal.
In children
After an attack of diarrhoea.
from loss of weight and consequent loss of fat in the ischiorectal fossae.
It may also be associated with cystic fibrosis, neurological causes and maldevelopment of the pelvis.
In adults
Third-degree haemorrhoids(commenst cause).
In the female, a torn perineum.
In the male straining from urethral obstruction, predispose to mucosal prolapse.
Partial prolapse may follow an operation for fistula in ano where a large portion of muscle has been divided.
In old age
Both mucosal and full-thickness prolapse are associated with weakness of the sphincter mechanism.
N.B: Prolapsed mucous membrane is pink; prolapsed internal haemorrhoids are plum coloured and more pedunculated. Presentation:
No pain, no Bleeding & prolapse doesn't reduce itself spontaneously.
Examination:
On examination, there are two type of prolapse:
Partial thickness prolapse ( Mucosal prolapse):
The mucous membrane and submucosa of the rectum protrude outside the anus for approximately 14 cm.
When the prolapsed mucosa is palpated between the finger and thumb, it is evident that it is composed of no more than a double layer of mucous membrane.
Most of the time it is not circumferential, on examination the anal sphincter is closed & when ask the patient to scream, part of the mucosa appear which is pinkish in colour.
Full-thickness prolapse:
The protrusion consists of all layers of the rectal wall and is usually associated with a weak pelvic floor.
It is more than 4 cm and commonly as much as 10–15 cm in length.
On palpation between the finger and thumb, the prolapse feels much thicker than a mucosal prolapse and consists of a double thickness of the entire wall of the rectum.
On examination and sphincter is patulous & on slight test effort, rectam will prolapse.
On chronic type you may see ulceration.
Any prolapse over 5 cm in length contains anteriorly between its layers a pouch of peritoneum. When large, the peritoneal pouch may contain small intestine, which have characteristic gurgle when the prolapse is reduced.
Differential diagnosis:
In the case of a child with abdominal pain, prolapse of the rectum must be distinguished from ileocaecal intussusception protruding from the anus. In rectosigmoid intussusception in the adult, there is a deep groove (5 cm or more) between the emerging protruding mass and the margin of the anus, into which the finger can be placed.
Treatment
Partial thickness prolapse
In infants and young children
Digital repositioning: The parents are taught to replace the protrusion, and any underlying causes are addressed.
Submucosal injections: If digital repositioning fails after 6 weeks’ trial, injections of 5 per cent phenol in almond oil are carried out under general anaesthetic. As a result of the aseptic inflammation following these injections, the mucous membrane becomes tethered to the muscle coat.
Surgery: Occasionally, surgery is required and, in such cases, the child is placed in the prone jack-knife position, the retrorectal space is entered, and the rectum is sutured to the sacrum.
In adults
Local treatments: Submucosal injections of phenol in almond oil or the application of rubber bands are sometimes successful in cases of mucosal prolapse.
Excision of the prolapsed mucosa: When the prolapse is unilateral, the redundant mucosa can be excised or, if circumferential, an endoluminal stapling technique can be used.
Full thickness prolapse
Perineal approach
Delorme's operation: In this procedure, the rectal mucosa is removed circumferentially from the prolapsed rectum over its length. The underlying muscle is then plicated with a series of sutures, so that, when these are tied, the rectal muscle is concertinaed towards the anal canal. The anal canal mucosa is then sutured circumferentially to the rectal mucosa remaining at the tip of the prolapse. The prolapse is reduced, and a ring of muscle is created above the anal canal, which prevents recurrence.
Altemeier's procedure:This consists of excision of the prolapsed rectum and associated sigmoid colon from below, and construction of a coloanal anastomosis.
Abdominal approach:
Abdominal rectopexy: we do midline incision or paramedian incision then do resection of the rectum to the lateral rectal ligament, then eitherinserting a sheet of polypropylene mesh between the rectum and the sacrum orhitching up the rectosigmoid junction with a Teflon sling to the front of the sacrum orsimply suturing the mobilised rectum to the sacrum using four to six interrupted non-absorbable sutures so-called ‘sutured rectopexy’.
Neoplasm of the rectum
Rectum is one of the most common site of Neoplasm.
Premalignant conditions:
Homosexuality.
Beef Consumption.
Colestectomy.
Chronic constipation ( low fiber in Diet)
premalignant lesions:
Polyps
Juvenile polyp:
It's benign.
Presentation: in infant & children, rounded material like cherry protrude from anus during defecation & can cause pain or bleeding.
On PR: bright-red glistening pedunculated sphere (‘cherry tumour’).
Treatment: surgery done under general anesthesia in prone position, you catch polyp with hard forceps & do transfixation then remove it.
Villous adenoma
Premalignant & could change to malignant.
Presentation: Diarrhea & sometimes Bloody tenched. The profuse mucous discharge from tumor, which rich in potassium, can cause dangerous electrolyte & fluid loss.
Examination: Frod like appearanc, very large & occationally fill the entire rectum.
Soft, freely mobile, supple & not fragile mean premalignant.
Endurated, fixed at the mucosa & hard mean malignant.
Treatment:
Small tumours can be removed by submucosal resection endoscopically, surgi-cally per anum or by sleeve resection from above.
Large tumor :rectal excision required. A technique known as transanal endoscopic microsurgery (TEM).