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WHEN CHRONIC CONSTIPATION AND RECTAL PROLAPSE TURN CRITICAL: A PEDIATRIC CASE OF RECTAL ABSCESS AND SEPTIC SHOCK
Fatema Ali
*, Dong Xi
pediatric gastroenterology, The University of Tennessee Health Science Center College of Medicine, Memphis, TN
Introduction:Rectal prolapse is a self-limited condition that usually occurs in children with risk factors such as constipation, diarrhea, cystic fibrosis, malnutrition, or pelvic floor muscle weakness. Local pain and self-limited mucosal bleeding are the most common complications. We present a case with a complicated rectal prolapse causing rectal abscess and septic shock.
Case Presentation:A 14-year-old male presented with a one-day history of fever and worsening rectal prolapse. He reported a chronic history of constipation requiring manual disimpaction and intermittent reducible rectal prolapse. Examination revealed reducible, thick, inflamed, and friable rectal mucosa. Laboratory studies demonstrated acute kidney injury, lactic acidosis, and elevated fecal calprotectin. Infectious stool studies were negative. CT imaging (figure 1) showed diffuse rectal wall thickening, perirectal fat stranding, and rectal lymphadenopathy. The patient developed septic shock requiring inotropic support and broad-spectrum antibiotics. Rigid sigmoidoscopy revealed shallow mucosal ulcerations confined to the rectum without necrosis, masses, or ischemia. MRI of the pelvis (figure 2) revealed a longitudinal abscess within the submucosal aspect of the rectal wall. Differential diagnoses included distal inflammatory bowel disease (IBD), pseudomembranous colitis, and complicated secondary ulceration due to long-standing rectal prolapse. The patient was treated with a 14-day course of antibiotics with no surgical intervention for the abscess due to incomplete walling and significant rectal edema. The patient was discharged on a robust bowel regimen, including daily stimulant and stool softener. At follow-up, the patient reported resolution of rectal prolapse but experienced fecal incontinence. Full-thickness rectal biopsy and endoscopy excluded Hirschsprung’s disease and IBD respectively, with normalization of fecal calprotectin and inflammatory markers. The bowel regimen was adjusted to improve fecal incontinence, but this resulted in the recurrence of rectal prolapse despite home pelvis floor exercises. This prompted plans for examination under anesthesia and ethyl alcohol 96% sclerotherapy.
Discussion:This case highlights a rare but severe complication of chronic constipation. It emphasizes the importance of aggressive treatment of constipation in children and adolescents, as well as the need to rule out underlying medical and surgical conditions. Conservative management for chronic rectal prolapse is first line, but surgical intervention may be necessary for refractory cases.
Figure 1: CT Pelvis with contrast showing dense wall thickening of the rectum, with pronounced stranding within the perirectal fat and enhancing perirectal lymphadenopathy
Figure 2: MRI pelvis: Diffuse circumferential rectal wall thickening with associated perirectal inflammatory tissue and fat proliferation
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