Rectal Perforation Caused by Anal Stricture After Hemorrhoid Treatment
A male patient, 67 years old, was admitted to the hospital via the emergency room, complaining of perianal pain he had been experiencing for the last month. The patient had also been suffering from constipation associated with hemorrhoids for a long time, and his symptoms, based on the criteria of chronic constipation, could be categorized as the Rome III criteria by using his medical history [,].\nAbout 30 years earlier, the patient had received injection sclerotherapy from an unlicensed therapist as treatment of his condition, but such injection caused fecal incontinence. Although the fecal incontinence was quickly resolved soon, constipation became even more severe and required medical treatment from other hospitals. Nonetheless, the symptoms did not improve; rather, they began to deteriorate about 10 years ago. Due to this progression, he received a hemorrhoidectomy twice at clinics of private practitioners. Notwithstanding such surgical procedures, the patient's symptoms deteriorated to the extent of having difficulty in defecation so that he had to use his finger, cotton rods, or tap water for evacuation of bowel contents.\nAt the time of visiting the emergency room, his blood pressure was 110/74 mmHg, his heart rate was 90 times/min, his respiratory rate was 16 times/min, and his body temperature was as high as 38.5℃. From the physical examination, abdominal tenderness was discovered, but other than that, there were no findings such as rebound tenderness or abdominal rigidity. On visual examination, fibrotic tissues of about 1.5 cm in size were found to be blocking the anal canal, so the doctor could not use his little finger for a digital rectal examination (). The patient had diabetes mellitus and benign prostatic hypertrophy as underlying diseases, and denied having any surgical history than the two hemorrhoidectomies about 10 years earlier. From hematological assay, the white blood cell count was 13,960/µL (neutrophils, 80.9%), hemoglobin was 14.9 g/dL, platelet count was 224,000/µL, and high sensitivity C-reactive protein was 7.74 mg/dL (reference range, 0 to 0.5 mg/dL). The abdominal computed tomographic scan taken at the time of visit to the emergency room showed fecal impaction in the colon and rectum with a large quantity, and focal perforation of the posterior rectal wall was confirmed by using the extraluminal gas shadow associated with soft tissue infiltration ().\nThe patient underwent emergency surgery based on the above examination results. Under general anesthesia, an anal examination was undertaken to check the conditions at the lithotomy position; then, a resection of the fibrotic tissues occluding the anus was performed, which enabled an approach through the anal canal. After the feces had been mechanically evacuated as much as possible, the rectum was washed using saline solution, followed by betadine solution. Thereafter, the patient was repositioned supine, and the sigmoid loop colostomy was constructed at the left lower abdomen for temporary colonic diversion due to rectal perforation. The patient was permitted to sip water on the second day after the operation, began to have a liquid diet on the third postoperative day, and was discharged on the fourth postoperative day. On the first postoperative visit to the out-patient department two weeks after the discharge, a digital rectal examination showed that feces still remained inside the anus. The patient had been undergoing conservative treatment with a warm-water Sitz bath at home, and the symptoms were quite improved in comparison to his preoperative conditions.