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Letters to the Editor
Spontaneous transvaginal small bowel evisceration: a case report
Rogério Serafim Parra, José Joaquim Ribeiro da Rocha, Omar Feres
Division of Coloproctology, Department of Surgery and Anatomy, School of Medicine of the University of São Paulo - Ribeirão Preto/SP, Brazil., Tel: 55 16 3621-1122
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Spontaneous evisceration through the vagina was first described in 1907 by McGregor&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> To date&#44; only eighty-five cases of transvaginal small bowel evisceration have been documented worldwide&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;2</a> The primary risk groups for spontaneous vaginal evisceration include postmenopausal women&#44;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;3</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib7">7</a> vaginal surgery cases&#44;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;8</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib10">10</a> multiparae&#44;<a class="elsevierStyleCrossRef" href="#bib11">11</a> and women of older age&#46;<a class="elsevierStyleCrossRefs" href="#bib2">2&#44;3</a></p><p id="para20" class="elsevierStylePara elsevierViewall">In postmenopausal woman&#44; transvaginal evisceration is frequently associated with increased abdominal pressure&#44;<a class="elsevierStyleCrossRef" href="#bib1">1</a> vaginal ulceration due to severe atrophy&#44; and straining at stool&#46;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;8</a></p><p id="para30" class="elsevierStylePara elsevierViewall">Vaginal evisceration is a medical emergency that requires prompt recognition and immediate surgical intervention&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> The associated mortality rate is 5&#46;6 percent&#59; however&#44; the incidence of morbidity is higher<a class="elsevierStyleCrossRefs" href="#bib3">3&#44;8</a> when the bowel has become strangulated through the vaginal defect&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">Here&#44; we report a case of vaginal vault rupture with evisceration through the vagina and highlight the risk factors&#44; clinical presentation&#44; and treatment options for this rare gynecological emergency&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE REPORT</span><p id="para50" class="elsevierStylePara elsevierViewall">A female patient aged seventy-five years was admitted to the emergency room with abdominal pain ten days after an angioplasty plus coronary stent implantation&#44; which had been performed through the femoral artery&#46; Three days after the angioplasty&#59; i&#46;e&#46;&#44; one week prior to presentation to the emergency room&#44; an inguinal hematoma developed as complication of the femoral arteriography had to be drained&#46; Thereafter&#44; the patient suffered from constipation and had difficulties with evacuation&#46; On the day the woman presented to the emergency room&#44; she felt a sudden and dull abdominal discomfort during evacuation and noticed a loop of bowel protruding from her vagina&#46; There was no history of abdominal or vaginal trauma&#46;</p><p id="para60" class="elsevierStylePara elsevierViewall">Thirty years prior to the present admission&#44; the woman had undergone a total abdominal hysterectomy for a benign pathology&#46; The operation had no complications&#44; and the patient&#8217;s recovery was uneventful&#46; After the hysterectomy and ten and twelve years prior to the present admission&#44; the woman had undergone two perinea surgeries for a prolapsed bladder&#46; Apart from these three surgeries&#44; the she had no past medical or gynecological history worthy of note&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">Upon admission to the emergency room&#44; the patient&#8217;s blood pressure was 110 &#215; 70 mmHg&#44; her heart rate was 88 bpm&#44; and an abdominal examination indicated significant pain&#46; The pelvic examination revealed 40 cm of small bowel prolapsing through her vagina &#40;<a class="elsevierStyleCrossRef" href="#f1-cln_65p559">Figure 1</a>&#41;&#46; After resuscitation of the patient&#44; she received intravenous broad-spectrum antibiotics &#40;1 g of Ceftriaxon and 500 mg of Metronidazole&#41;&#44; and her bowel was wrapped with warm&#44; sterile&#44; and saline-soaked gauze for transfer to the operating room&#46; There&#44; under rachianesthesia&#44; the woman was placed in lithotomy position&#44; so that the viability of her small bowel could be assessed&#46; The examination revealed that the bowel was edematous and thick-walled&#44; but still viable&#46; There was no evidence of necrosis&#46; The inguinal hematoma&#44; which looked infected&#44; was drained &#40;<a class="elsevierStyleCrossRef" href="#f2-cln_65p559">Figure 2</a>&#41;&#46; The patient was then placed in the Trendelenburg position&#46; Because the vault defect was located high in the vagina&#44; all attempts to transvaginally reduce the small bowel into the peritoneal cavity were unsuccessful&#46; Consequently&#44; a midline subumbilical incision was made&#44; and the prolapsed bowel was reduced into the abdomen and inspected for damage throughout its length&#46; Thereafter&#44; the vaginal vault defect was closed with absorbable sutures &#40;Polygleprone 2&#46;0&#41; by a vaginal route &#40;<a class="elsevierStyleCrossRef" href="#f3-cln_65p559">Figure 3</a>&#41;&#44; and a 30-cm segment of bowel was excised&#46; Although the bowel was viable&#44; we decided to carry out this procedure because there was an expansible hematoma in the mesum&#46; Broad-spectrum antibiotics were postoperatively given for six days&#46; The patient had no postoperative complications and was discharged from the hospital after six days&#46; In a follow-up examination three months later&#44; the woman exhibited no evidence of recurrence&#44; and the vaginal vault had healed satisfactorily&#46;</p><elsevierMultimedia ident="f1-cln_65p559"></elsevierMultimedia><elsevierMultimedia ident="f2-cln_65p559"></elsevierMultimedia><elsevierMultimedia ident="f3-cln_65p559"></elsevierMultimedia></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para80" class="elsevierStylePara elsevierViewall">Vaginal evisceration is a rare event that has been reported to occur after vaginal traumas induced by coitus&#44; obstetric instrumentation&#44; and the insertion of foreign bodies&#46; Vaginal evisceration has also been reported after pelvic surgery and in patients with enterocele&#46;<a class="elsevierStyleCrossRef" href="#bib8">8</a> The risk groups for transvaginal small bowel evisceration include the elderly&#59; postmenopausal women&#59;<a class="elsevierStyleCrossRefs" href="#bib2">2&#44;7</a> female patients after vaginal&#44;<a class="elsevierStyleCrossRefs" href="#bib9">9&#44;10&#44;12</a> abdominal&#44;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#8211;<a class="elsevierStyleCrossRefs" href="#bib6">6&#44;13</a> or laparoscopic hysterectomy&#59; <a class="elsevierStyleCrossRef" href="#bib14">14</a> and multiparous women&#46;<a class="elsevierStyleCrossRef" href="#bib11">11</a> Due to the weakening of vaginal tissue caused by genital atrophies and enteroceles&#44; the risk of spontaneous evisceration is increased in postmenopausal women&#44; particularly in combination with straining at stool and&#47;or vaginal ulceration&#46;<a class="elsevierStyleCrossRefs" href="#bib8">8&#44;15</a> Because the postmenopausal vagina is thin&#44; scarred&#44; foreshortened&#44; and has diminished vascularity&#44; it is more prone to rupture&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;4</a> In postmenopausal women&#44; vaginal ruptures most commonly occur at the posterior fornix&#46;<a class="elsevierStyleCrossRefs" href="#bib8">8&#44;16</a></p><p id="para90" class="elsevierStylePara elsevierViewall">In postmenopausal women&#44; evisceration can occur either spontaneously or&#44; more frequently&#44; in connection with an increase in intra-abdominal pressure induced by coughing&#44; defecating&#44; or falling&#46;<a class="elsevierStyleCrossRef" href="#bib11">11</a> In premenopausal patients&#44; evisceration is usually preceded by vaginal trauma caused by rape&#44; coitus&#44; obstetric instrumentation&#44; or the insertion of foreign bodies&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;3&#44;8&#44;16</a> Additional risk factors for vaginal evisceration include previous vaginal surgeries and enteroceles&#46;<a class="elsevierStyleCrossRef" href="#bib8">8</a> According to Kowalski <span class="elsevierStyleItalic">et al&#46;</span><a class="elsevierStyleCrossRef" href="#bib2">2</a>&#44; 73 percent of patients with vaginal evisceration had previously undergone some kind of vaginal surgery&#44; most commonly transvaginal hysterectomies or enterocele repairs&#46; In 63 percent of the reported cases&#44; the patients had enteroceles&#44; which putatively caused further stretching of the atrophic vagina&#44; thus making it more susceptible to rupture&#46; Of all the eighty-five cases of vaginal evisceration reported in the literature to date&#44;<a class="elsevierStyleCrossRef" href="#bib8">8</a> 50&#8211;75 percent of the patients had undergone one or more previous vaginal operations&#44;<a class="elsevierStyleCrossRefs" href="#bib3">3&#44;8</a> and roughly 25 percent of the eviscerations occurred after abdominal hysterectomy&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a> Postoperative cuff infections after hysterectomy have also been shown to contribute to evisceration&#46;<a class="elsevierStyleCrossRef" href="#bib13">13</a> So far&#44; there are no reported cases of vaginal vault rupture and evisceration due to perineal proctectomy or rectal prolapse&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">In the present case&#44; one of the underlying causes of the evisceration was probably the fact that the patient was a postmenopausal woman with previous history of pelvic surgeries &#40;hysterectomy and perinioplasty&#41;&#44; which putatively had weakened her pelvic floor and consequently contributed to the vaginal rupture&#46; A second cause for the evisceration was excessive strain due to the difficulty in evacuating in the presence of a retroperitoneal hematoma&#46;</p><p id="para110" class="elsevierStylePara elsevierViewall">Vaginal evisceration is a surgical emergency&#44; and immediate recognition and surgical repair are crucial for its successful management&#46; The appropriate management of evisceration includes a thorough assessment of the herniated viscus and surgical repair of the vaginal defect&#46; In cases where the eviscerated bowel is viable and can be reduced into the peritoneal cavity without complication&#44; the closure of the vaginal defect can be accomplished by a vaginal approach&#59;<a class="elsevierStyleCrossRef" href="#bib2">2</a> however&#44; in patients with minimal or no enterocele&#44; the vaginal defect may be located high in the vagina&#44; as was the case in the present study&#46; Under these circumstances&#44; a vaginal approach is not viable because the bowel&#44; which becomes trapped and strangulated after protruding through the defect&#44; prevents access to the defect itself&#46; In these cases&#44; laparotomy is necessary to access the defect&#44; reduce the bowel into the abdomen&#44; and resect any nonviable bowel&#46; To date&#44; all the reported cases that have required bowel resection have been managed with exploratory laparotomy followed by repair of the vaginal defect&#46;<a class="elsevierStyleCrossRefs" href="#bib2">2&#44;17</a> A combined abdominal and vaginal surgical approach&#44; as the one used in the present case report&#44; is recommended for adequate evaluation and effective repair of the tissues involved&#46;<a class="elsevierStyleCrossRef" href="#bib11">11</a></p></span></span>"
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Article information
ISSN: 18075932
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos