An unusual stab wound to the buttock
A 47-year-old diabetic man had a stab wound to his right buttock inflicted by his roommate using a kitchen knife. On examination, his pulse was 75 beats/min and his blood pressure (BP) was 100/50 mmHg. The abdomen was soft and not tender. A single wound was seen on the medial side of the right gluteal area superior to the intertrochanteric plane []. No neurological deficits were detected. Arterial pulses of the lower limbs were well-felt. The wound was sutured in the Emergency Department and patient was scheduled for discharge. Patient felt dizzy, complained of fresh bleeding per rectum and fainted before being sent home. At this stage, his pulse rate was 105 beats/min and his BP had dropped to 65/40 mmHg. Patient was resuscitated with crystalloids and he became hemodynamically stable. Rigid sigmoidoscopic examination was performed under general anesthesia and showed blood clots in the rectum with no active bleeding. No obvious injury to the rectal wall was seen despite the injection of methylene blue through the gluteal wound. Patient was admitted to the surgical ward for close observation. He was kept fasting, had intravenous fluids and antibiotics were administered. Two days later, patient complained of lower abdominal pain. Fecal matter passed through the gluteal wound. Patient had a temperature of 38°C. There was tenderness and guarding in the lower abdomen. Abdominal computed tomography (CT) scan with oral, rectal and intravenous contrast was performed. It showed contrast leakage from the posterior wall of the rectum, intraperitoneal free air and air in the mesentery around the rectum [Figures and ]. Exploratory laparotomy was performed. No intraperitoneal fecal soiling was seen. Nevertheless, there was a significant amount of air in the retroperitoneal space and in the bowel mesentery []. The rectum was mobilized, but the extraperitoneal perforation could not be seen. Hartmann's procedure was performed. Gluteal wound exploration revealed a deep laceration lateral to the edge of the sacrum. Debridement of the necrotic tissue was performed. Post-operatively, patient had slow recovery because of intestinal ileus. The colostomy started to function on the fourth post-operative day. Patient recovered completely at day 10 and was scheduled for reversal of the Hartmann's procedure 12 weeks after surgery. He decided to travel overseas to his home country to continue his treatment.