Intraperitoneal rectal injuries will cause
peritonitis, sepsis and even death if not detected early. Intraperitoneal free air (IFA) is usually diagnosed by an erect Chest X-ray . If the erect chest X-ray was normal, then an abdominal CT scan is recommended. Point-of-care ultrasound has been recently used to detect IFA [3, 4]. Hereby, we report an unusual case of trans-anal rectal injury in which point-of-care ultrasound was of a great help for an early diagnosis. Case presentation A 45-year-old male presented to the Emergency Department complaining of lower abdominal pain and dysuria of two days duration. His blood pressure was 120/80 mmHg, his pulse was 107 beat per minute and his temperature Integrin inhibitor was 36.8°C. Abdominal examination revealed tenderness and
guarding in the lower EX 527 in vivo abdomen. Surgeon-performed portable point-of-care ultrasound as an extension of the abdominal examination was done immediately and revealed an inflamed omentum with hypoechoic stranding in the right upper quadrant (Figure 1A), thickened non compressible small bowel (Figure 1B), and free fluid in the pelvis. A transverse abdominal section of the right upper quadrant showed free intraperitoneal air (Figure 2). Rectal examination revealed a large longitudinal rectal tear 8 cm from the anal verge with an inflamed floppy mucosa. The patient admitted that he has inserted a glass bottle through his anus two days before, which was associated with sudden Janus kinase (JAK) lower abdominal pain and a small
amount of rectal bleeding. Erect chest X-ray confirmed the presence of air under the diaphragm (Figure 3). C-reactive protein was 418 mg/L (Normal less than 0.7 mg/L), serum creatinine was 139 micromol/L (normal less than 107 micromol/l) and white blood cell count was 13.8 × 109/L. Arterial blood gas has shown an arterial oxygen tension of 50 mmHg on normal air. Laparotomy has confirmed the sonographic findings with thickened omentum, an edematous small bowel, pelvic abscess, and a 12 cm intraperitoneal tear of the anterior wall of the rectum which was necrotic (Figure 4). The rectum was Compound C dissected and transected 8 cm from the anus. Low mesorectal excision of the necrotic rectum and a Hartman’s procedure was performed. Two surgical drains without suction were left in the pelvis. Postoperatively, the patient was ventilated in the ICU. His arterial oxygen tension was 80 mmHg using an oxygen concentration of 50%. The patient received Tazocine intravenously 4.5 gms 8 hourly and Clexane 40 mg subcutaneously daily for one week. His respiratory and renal functions became normal within 4 days. The patient was discharged home on day 10 with good general condition and he is planned for reconnection of the colon after 3 months.