Case Report

Spontaneous Transvaginal Evisceration of the Small Bowel

P.S. Ramanujam, MD; K.S. Venkatesh, MD; Krishna P. Ramanujam

Spontaneous small-bowel evisceration through the vagina is a rare event.1-4 Transvaginal small-bowel evisceration is more common in elderly postmenopausal women.1-5 Other risk factors include a history of vaginal surgery and/or trauma.4,6-9 The two patients presented here had a history of enterocele repairs.

CASE REPORTS

Case 1

A 76-year-old woman presented to the hospital emergency department with severe abdominal pain and 30 cm of small bowel prolapsing through her vagina. The patient reported that she had felt sudden lower abdominal pain with associated vaginal pressure and fullness when she bent down to pick up a golf ball. She had a history of vaginal hysterectomy and enter-ocele repair 6 months prior to presentation.

Initial examination revealed an alert, diaphoretic woman with stable vital signs. The abdomen was tender, with signs of diffuse peritoneal irritation. Pelvic examination showed approximately 30 cm of very congested small bowel protruding through the vaginal introitus.

After intravenous (IV) resuscitation, the patient�s prolapsed bowel was wrapped with sterile gauze soaked in saline solution, and she was transferred to the operating room. A midline laparotomy was performed, and the loop of small bowel that was protruding through the tear in the vaginal cuff was reduced into the abdominal cavity with gentle abdominoperineal manipulation. The prolapsed ileal loop was viable. The vaginal defect was closed with 2-0 polypro-pylene suture and an omental flap. The patient had an uneventful recovery.

Case 2

An 82-year-old woman was brought to the hospital emergency department with loops of bowel protruding from her vagina (Figure). The patient reported that the prolapse occurred when she was straining during a bowel movement. The patient was resuscitated with IV fluids, and an IV antibiotic was administered. She was transferred to the operating room, and the prolapsed bowel was wrapped with sterile gauze soaked in saline solution. After laparotomy, the bowel was reduced with gentle abdomino-perineal manipulation. The prolapsed ileal loop was congested but viable. There was a defect at the apex of the vaginal cuff, which was the site of previous enterocele repair. The defect was closed with nonabsorbable polypropylene suture, and reinforced with an omental patch. The patient�s recovery was uneventful.

Figure not available online

FIGURE . Multiple loops of small bowel eviscerated through the vagina. Courtesy of P.S. Ramanujam, MD, and K.S. Venkatesh, MD.

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DISCUSSION

Transvaginal evisceration of the small bowel is a rare condition, with approximately 80 cases reported in the literature.1,4 Virtanen et al2 found 71 cases in a literature review, and reported one more in 1996. Kowalski et al4 reviewed the world literature for vaginal small-bowel evisceration in postmenopausal women in 1996. Risk factors for evisceration include older age, a history of vaginal surgery, and the presence of enterocele.4-6 The vaginal wall in postmenopausal women is typically thin, scarred, and shortened, which makes it more susceptible to rupture. The most common location for spontaneous rupture is at the posterior fornix.6,7 Small-bowel evisceration in premenopausal women is usually preceded by trauma due to coitus, rape, obstetric instrumentation, or foreign-body insertion.5-10 In postmenopausal women, evisceration can occur after a sudden increase in intra-abdominal pressure (eg, straining, coughing, defecating). Evisceration has also been described following vaginal hysterectomy, abdominal hysterectomy, enterocele repair, and perineal proctectomy.1,4,5,11-13

Of postmenopausal women with small-bowel evisceration, 73% had some type of vaginal surgery, most commonly vaginal hysterectomy or enterocele repair.4 The presence of enterocele in an already atrophic vagina makes it more susceptible to rupture.4,5,12 There has been one reported case of vaginal vault rupture with small-bowel evisceration after perineal proctectomy.1

Urgent management of small-bowel evisceration through the vagina is critical to avoid complications such as small-bowel ischemia, infection, ileus, and deep vein thrombosis. After establishing the diagnosis, immediate surgery is mandatory.4-8,10 Antibiotic treatment is appropriate to reduce the risk of infection.1,2 The eviscerated bowel should be cleansed with sterile saline solution and wrapped in moist towels.1,4,8 An abdominal approach is imperative. The bowel is reduced by gentle traction with bimanual manipulation and reduction. After reduction, the bowel is carefully examined for viability. Next, the vaginal defect is closed with nonabsorbable suture. An omental patch can be applied if available.1,3 A successful laparoscopic and vaginal approach with omental patch has been described by Narducci et al.13

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CONCLUSION

Small-bowel evisceration through the vagina is a rare occurrence. Immediate surgery combining an abdominal, anal, and vaginal approach yields the best results.

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P.S. Ramanujam, MD, is staff colon and rectal surgeon, Department of Surgery, Walter O. Boswell Memorial Hospital, Sun City, Ariz. K.S. Venkatesh, MD, is staff colon and rectal surgeon, Department of Surgery, Desert Samaritan Hospital, Mesa, Ariz. Krishna P. Ramanujam is a student researcher and editor-in-chief of Pre-Med Perspectives, Department of Molecular and Cellular Biology, University of California, Berkeley.

References

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