Rectovesical Fistula Secondary To Perianal Impalement Injury In A 10-Year-Old Child
Year : 2019 | Volume : 47 | Issue : 0 | Page : 59
MJWI.2020/22
Minakshi Bhosale , Swati Ullal ,
Date of Web Publication 09-May-2019
Rectovesical Fistula Secondary To Perianal Impalement Injury In A 10-Year-Old Child Abstract : Impalement injuries are uncommon, especially in the pediatric population. There are very few reports on pediatric impalement and only one reported case of pediatric rectal impalement injury with bladder rupture. We report case of a 10-year-old boy with accidental trauma to the perineum, resulting in big anterior rectal wall perforation just below the peritoneal reflection and extra-peritoneal perforation of the urinary bladder, resulting in a wide rectovesical fistula and urinary drainage from the rectum. Two consecutive surgeries were performed to manage this unusual and complex case with excellent outcome. This report is presented for an extremely rare and yet undescribed presentation of perianal impalement injury in a child.Keywords : Perianal Impalement Injuries, Child, Rectal Perforation, Extraperitoneal Bladder Injury, Rectovesical FistulaIntroduction : Pediatric perianal impalement injuries are relatively infrequent. They result from accidents, gunshot injury and medical treatment.[1] The damage caused by an overly small looking impalement injury may go unnoticed at the outset; but it may lead to significant tissue damage with resultant morbidity and mortality from delay in diagnosis. In order to diagnose these injuries in time, it is important to follow a well-organized workup protocol including combination of radiology, endoscopy and open surgical techniques.[1,2] Case Report: A 10-year-old boy had accidental trauma to the left buttock by a sharp wooden object, while playing. There was bleeding from the wound after removal of the object. He presented to us one and half day later with fever, bilious vomiting and inability to void urine per urethra (for about 36 hours). There was history of passage of stool, blood and copious watery fluid drainage from the anus after the incident. On examination, he was febrile, dehydrated and had tachycardia of 160/min. His blood pressure was 90/60 mm of Hg and respiratory rate was 40/min. Abdomen was guarded. A small entry wound of 1.5× 1cm was noted on the left buttock (Fig 1). On Foley catheterization of the urinary bladder, fecal matter could be seen in the tubing. Further examination of the fistulous tract and per rectal examination was deferred at this juncture, for a detailed assessment under anaesthesia. His hematological investigations showed hemoglobin 9 gm%, WBC count 15,000/cmm, blood urea nitrogen of 28 and normal serum electrolytes. Erect X-ray abdomen and pelvis was normal. Ultrasonography was inconclusive. Dual contrast computerized (CT) scan of the abdomen and pelvis showed a fistulous tract between the posterior bladder wall and colon with air specks around rectum (Fig 2). There was no solid organ injury or free fluid in abdomen. After adequate fluid resuscitation and hemodynamic stabilization, he was examined under anaesthesia in the operation theatre. Examination of the fistulous tract was non-contributory. A big anterior rectal wall defect was identified about 7-8 cm above the anal verge on per rectal examination. Tip of the examining finger in rectum could be felt on bimanual examination. There was evacuation of blood mixed, dark green liquid stool on removal of the examining finger. Abdomen was explored through Pfannensteil incision. An anterior wall rectal perforation of 2 cm diameter was found just below the peritoneal reflection (Fig 3). There was extra-peritoneal bladder perforation ~ 1.5 cm in diameter over the base of the bladder (Fig 4). Rectal perforation were closed as a single layer (after freshening the edges) using 3-0 Polyglycolic acid, interrupted sutures. Bladder perforation was closed in two layers using 3-0 Polyglycolic acid over an indwelling 12 Fr Foley catheter. Lavage was given in the pelvis. Right transverse colostomy was performed through separate right upper transverse incision, matured, contents evacuated and distal loop washouts given on table. Blood transfusion of 200 cc was also given. Post-operatively, oral feeds were started since post-operative day 3. Intravenous Tazobactum, Amikacin and Metrogyl were given for 14 days. He also received Aminodrip transfusion (5%) in view of poor nutritional status. Urinary leak from the rectum continued for about 15 days post-operatively, but the post-operative course was uneventful thereafter. Urinary catheter was removed after 21 days. Colostomy was closed 6 months later. Presently, at a follow up of 2 years, the child is asymptomatic and growing well. All the wounds have healed well. His fecal continence is normal.Discussion : Pediatric perianal impalement injuries involve foreign body trauma to the anus, rectum or the urinary bladder resulting in intra- or extraperitoneal rupture. Clinical findings are sometimes innocuous, but can be life threatening. Assessment of suspected impalement injury should comprise careful history and thorough physical examination.[2,3] Evaluation of involvement of the anal sphincter is crucial in deciding the therapeutic approach. Because of small numbers of impalement related anorectal injuries in children and since their severity is not reflected accurately by the external appearance, there may be difficulty in recognizing and/or properly treating such injuries. Current standards of management are Primary repair, fecal diversion, wound drainage and broad spectrum antibiotics.[1,4,5] Our case, a 10-year-old boy had accidental trauma to the left buttock by a sharp wooden stick. He presented 36 hours later with passage of stool, blood and watery fluid from the anus. There was fever, bilious vomiting and non passage of urine per urethra for about 36 hours. CT scan of the pelvis showed a fistulous tract between the posterior wall of bladder and recto-sigmoid region, though ultrasonography was inconclusive. On exploration, a big anterior rectal perforation of 2 cm diameter was identified. There was bladder perforation of ~ 1.5 cm in size over the base of the bladder. Rectal perforation was closed using interrupted sutures. Bladder perforation was closed in two layers over 12 Fr Foley catheter. Transverse colostomy was done to protect the suture lines. et al have reported a case of rectal impalement with extraperitoneal bladder injury in a 12-year-old boy.[3] et al have reported a case rectal impalement injury associated with through-and-through bladder rupture (intraperitoneal bladder rupture) in a 9-year-old boy.[6] et al have presented an account of management of impalement injury involving the posterior bladder wall and two wounds in the rectum in a 45-year-old man. The diagnosis was made by cystoscopy, fiberoptic colonoscopy and diagnostic laparoscopy. Transanal closure of fistulas was done and bladder injury was managed by indwelling ureteral and urethral catheters.[7] However, none of the cases reported so far had injuries akin to our case. No similar report was found even on thorough literature search. Pediatric perianal impalement injuries involving the rectum and urinary bladder require experience with trauma, colo-proctological surgery and knowledge of all available surgical options. Primary repair along with diverting colostomy offers the best chance of healing and successful outcome. One should not overlook overtly small looking impalement injury, since the damage caused may be of great magnitude and not represented by size of the external injury. It may result in deleterious complications including death if not properly managed. The importance of digital rectal examination under anaesthesia should be an integral part of all assessment protocols. References :, , , . Perianal and rectal impalement injuries. 2006;77:781-9., , , . Rectum perforation after broomstick impalement in a 17-year-old : Case report and review. 2013;29:510-2. , , , . Pediatric anorectal impalement with bladder rupture : Case report and review of the literature. 2006;41:1-3., , . Impalement and anorectal injuries in childhood : A retrospective study of 12 cases. 1998;33:1287-91., , , , , . Management of anorectal injuries in children: an eighteen-year experience. 2003;13:249-55., , , . Intraperitoneal and extraperitoneal bladder rupture secondary to rectal impalement. 1995;38:818-9., , . Extraperitoneal bladder rupture secondary to rectal impalement. 2001;8:634-6.
