Gulten Kiyak  ( Department of General Surgery, Ankara Ataturk Teaching and Research Hospital, Turkiye )
Emre Ergul  ( Department of General Surgery, Ankara Ataturk Teaching and Research Hospital, Turkiye )
Ali Celik  ( Department of General Surgery, Ankara Ataturk Teaching and Research Hospital, Turkiye )

Madam, spontaneous perforation of the rectum with evisceration of small intestine through the anus especially with rectal prolapse, is an extremely rare condition with a high mortality rate. The etiology of spontaneous rupture is not clear, but can be assumed to be mechanical strain and possibly a local disturbance of blood perfusion in the rectum when in a state of prolapse.¹ Blood perfusion disorder which is the most common cause of the ischaemia may not result in necrosis. Also it can be an effect of necrosis due to atherosclerosis.²
We came across a 67-year-old female patient who was admitted to our emergency department with the complaint of evisceration of small bowel through the anus (Figure.1). The patient was in severe pain. Her general condition was good. She had been suffering from rectal prolapse for years, which she had been managing herself. But this time she could not reduce it. On physical examination, the protruding small intestine was viable, so an emergency surgery was performed.[(0)]
The small intestine, which was protruding through the anus, was reduced with gentle manipulation. Small intestine resection or repair was not required.  We observed a 7cm longitudinal tear at the rectum just above the peritoneal fold. The margins of the tear were viable. Perforation was repaired with primary suture and a protecting loop sigmoidostomy procedure was performed.
Metronidazole and Ceftriaxon was given after the surgery. Peroral nutrition was started on second postoperative day. There were no postoperative complications except wound infection. She was discharged on 20th postoperative day.
The most common reported treatment is reduction of the bowel followed by primary suture of the rectum, with or without a protecting colostomy proximally.¹ Shoab et al suggested that Thiersch repair is an option to be considered in elderly patients with spontaneous rectum perforation.³ The technique requires placing the patient in the Lloyd-Davies position, then repositioning the prolapsed small bowel through the rectal tear after copious irrigation and cleansing. Repair of the Rectal tear with PDS is done trans-anally by applying  Thiersch stitches for the rectal prolapse.

1. Hultgren T. Spontenous rupture of the rectum with evisceration of small intestine through the anus. A case report. Acta Chir Scand 1986;152: 239-40.
2. Ludwig K, Schuster R. Spontaneous rectal perforation with prolapse of the small intestine. Zentralbl Chir 1984; 109: 358-59.
3. Shoab SS, Saravanan B, Neminathan S, Garsaa T. Thiersch repair of a spontaneous rupture of rectal prolapse with evisceration of small bowel through anus - a case report. Ann R Coll Surg Engl. 2007 ;89:6-8.