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BMJ Case Reports 2016; doi:10.1136/bcr-2016-216573

Spontaneous transvaginal small bowel evisceration 40 years post-abdominal hysterectomy

  1. Philippe Froment3
  1. 1Department of General Surgery, Hopital Riviera-Chablais, Montreux, VD, Switzerland
  2. 2Department of Radiology, HFR Fribourg Hopital Cantonal, Fribourg, Switzerland
  3. 3Hopital Fribourgeois Site de Riaz, General Surgery, Riaz, FR, Switzerland
  1. Correspondence to Dr Floryn Cherbanyk, floryn.cherban{at}yahoo.fr
  • Accepted 27 July 2016
  • Published 10 August 2016

Description

A 77-year-old female patient known for chronic constipation presented to the emergency room with abdominal and perineal pain that appeared following straining in the toilet a few hours previously. No vomiting had occurred. On examination, it was found that ∼1 m of the small intestine, free of peritoneum, was protruding through the vagina (figure 1). The prolapsed intestinal loops were congested but appeared viable and contracted when touched. Examination of the anus was unremarkable. The patient was known to have had a total abdominal hysterectomy 40 years previously for uterine fibroids. She had also had a right hemicolectomy and a right inguinal hernia repair in the previous decade.

Figure 1

Transvaginal evisceration of the small bowel as seen in the emergency room.

The patient was stable with no fever, a blood pressure of 167/66 mm Hg and a pulse rate of 60/min. Laboratory results were unremarkable. An abdominal CT scan was then performed, showing a protrusion of the small intestine into the vagina through a defect in the vaginal cuff (figure 2A, B).

Figure 2

(A and B) Coronal and sagittal CT scan images showing small bowel evisceration through the vagina.

An urgent explorative laparotomy was performed through a subumbilical midline incision. The prolapsed segment of intestine was reduced by manual traction and was found to be perfectly viable. No resection was therefore necessary. A 3 cm opening was found in the vaginal vault. This was closed with absorbable sutures and covered with an omental flap.

The patient made an uneventful recovery and was discharged on day 9. Follow-up examinations at 6 weeks and 6 months were unremarkable.

First described by Hyernaux in 1864, evisceration of the bowel through the vagina is a rare event, with <100 cases described in the literature.1 It most commonly affects postmenopausal women (mean age of 62 according to Croak) with a history of hysterectomy or vaginal surgery.2 It can occur spontaneously or after any sort of vaginal trauma such as rough intercourse or vaginal examination. Although it usually presents with a less dramatic clinical picture then in the case illustrated here, urgent intervention is required in order to prevent complications such as bowel obstruction and ischaemia. Treatment options include transvaginal or laparoscopic repair as well as laparotomy, depending on how easily the eviscerated bowel can be reduced. Even with surgical intervention, mortality rate remains as high as 6%.3 A high index of suspicion and a pelvic examination are therefore required when dealing with elderly female patients with abdominal pain accompanied by vaginal symptoms and a history of hysterectomy or vaginal surgery.

Learning points

  • Vaginal evisceration is a rare but life-threatening condition requiring urgent surgical intervention.

  • It most commonly occurs in postmenopausal, multiparous females with a history of hysterectomy or vaginal surgery.

Footnotes

  • Contributors FC and J-LG were responsible for database search and writing the article. PF performed the surgery and supervised the writing of the article. DH interpreted the radiological images and for the CT reconstructions.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

References

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