A perforated rectum is a serious medical emergency defined by a full-thickness tear or hole in the wall of the rectum, the final section of the large intestine. This breach allows bowel contents, including fecal matter and bacteria, to leak into the abdominal cavity, rapidly causing severe inflammation and infection known as peritonitis. If untreated, this contamination progresses quickly to a life-threatening systemic infection called sepsis, requiring immediate medical attention.
Primary Causes of Rectal Perforation
Perforations arise from three broad categories: medical procedures, physical trauma, or underlying disease. Many perforations are iatrogenic, resulting from complications during diagnostic or therapeutic procedures. The most common procedural cause is injury during a colonoscopy, particularly when removing large polyps or operating on patients with thin bowel walls. Other causes include surgical complications during urologic or gynecologic operations, where the rectum is inadvertently damaged due to its close proximity to pelvic organs.
Traumatic injury is another major cause, often involving blunt force or penetrating wounds to the abdomen or pelvis. This category also includes injuries caused by foreign body insertion, which creates a direct mechanical tear. In rare instances, severe constipation can lead to a stercoral perforation, where a hardened mass of stool causes pressure necrosis and erosion through the rectal wall.
Disease-related perforations occur when chronic conditions weaken the rectal tissue until it ruptures. This is frequently seen in severe inflammatory bowel disease, such as Crohn’s disease or ulcerative colitis, where deep inflammation compromises the integrity of the bowel wall. Other disease processes like advanced rectal cancer or severe diverticulitis can also erode through the tissue, creating a defect that leads to leakage.
Recognizing the Symptoms
The presentation of a perforated rectum is acute, reflecting severe contamination of the abdominal space. Patients experience the sudden onset of intense, unrelenting abdominal pain that does not improve. This pain may initially localize to the lower abdomen but becomes diffuse and widespread as peritonitis develops.
Systemic signs of infection, indicating the body’s reaction to bacterial spillage, follow quickly. These include fever and chills. Nausea and vomiting are common as the inflamed abdomen attempts to shut down digestive processes.
As the condition progresses toward septic shock, patients may exhibit an elevated heart rate (tachycardia) and low blood pressure (hypotension). The abdomen often becomes distended, rigid, and extremely tender (guarding). These symptoms, especially following a recent procedure or injury, require an immediate trip to the emergency room, as treatment delays increase the risk of death.
Diagnostic Procedures
Diagnosis begins with a physical examination and assessment of vital signs. The physician looks for abdominal rigidity and tenderness, hallmark signs of peritonitis, and checks for signs of shock like low blood pressure or a rapid pulse. Blood tests are drawn immediately to look for an elevated white blood cell count, signaling infection, and signs of organ dysfunction related to sepsis.
Imaging studies are the definitive tool for confirming the diagnosis and locating the tear. While a simple X-ray can sometimes reveal free air under the diaphragm, a Computed Tomography (CT) scan is the preferred test. The CT scan, often performed with intravenous contrast, is highly sensitive and precisely locates the tear.
The CT scan provides information that guides surgical planning. It visualizes extraluminal air that has leaked into the abdominal space and identifies collections of fluid or abscesses. It also helps determine the cause of the perforation, such as diverticulitis or a tumor, allowing surgeons to prepare for the specific repair.
Immediate Treatment and Surgical Intervention
Immediate management focuses on stabilizing the patient and controlling the infection source. Stabilization involves aggressive fluid resuscitation with intravenous (IV) fluids to counteract shock and the immediate administration of broad-spectrum IV antibiotics. These medications fight the bacterial contamination that has leaked from the rectum into the abdominal cavity.
Definitive treatment requires emergency surgery to close the defect and clean the abdominal cavity. The surgical approach depends on the perforation size, fecal contamination, and the patient’s stability. For small, rapidly diagnosed perforations with minimal contamination, a primary repair may be attempted by suturing the tear closed, often without diverting the fecal stream.
If the perforation is large, contamination is significant, or the patient is unstable, a fecal diversion procedure is necessary. This involves creating a temporary or permanent stoma (colostomy) to reroute fecal flow away from the injured rectum. The damaged section may be repaired or, in cases of extensive damage or severe underlying disease, removed entirely.
The colostomy allows the contaminated rectum to rest and heal without the passage of stool, reducing the risk of the primary repair failing. This two-stage approach prioritizes controlling the severe infection over restoring normal bowel function. The decision between primary repair or diversion is made in the operating room based on tissue condition and patient status.
Recovery and Long-Term Outlook
Recovery following surgery is prolonged due to the severity of the initial infection. Most patients require a hospital stay of five to seven days, and full recovery can take six to eight weeks. Postoperative care includes monitoring for lingering infection and managing the surgical wound.
Potential complications include the formation of an intra-abdominal abscess requiring drainage, or a surgical site infection. Patients may also experience fatigue and altered bowel habits. The long-term outlook is tied to the timeliness of the diagnosis and intervention.
If a colostomy was performed, it is usually temporary. After the rectum has fully healed (typically several months), a second operation, known as a colostomy reversal, is performed to reconnect the bowel and restore function. Patients who receive rapid diagnosis and definitive surgical treatment generally have a favorable long-term outcome, though ongoing medical management may be needed if the perforation was caused by a chronic condition like inflammatory bowel disease.