What is the management for a patient (Pt) with rectal prolapse and active bleeding?

Management of Rectal Prolapse with Active Bleeding

In patients with rectal prolapse and active bleeding, urgent surgical treatment is recommended after initial stabilization and assessment. 1

Initial Assessment and Stabilization

• Perform focused assessment of:

  • Hemodynamic stability (vital signs)
  • Complete blood count
  • Serum creatinine
  • Inflammatory markers (CRP, procalcitonin, lactates) 1
  • Extent of bleeding and prolapse

• For hemodynamically stable patients:

  • Perform contrast-enhanced abdomino-pelvic CT scan to detect complications and assess for colorectal cancer 1
  • Do not delay appropriate treatment to perform imaging in unstable patients 1

Management Algorithm

1. Hemodynamically Unstable Patients

• Immediate surgical intervention without delay for conservative management 1
• Abdominal open approach is strongly recommended 1
• Administer empiric antimicrobial therapy due to risk of intestinal bacterial translocation 1

2. Hemodynamically Stable Patients with Active Bleeding

• Attempt gentle manual reduction under mild sedation or anesthesia if no signs of ischemia/perforation 1
• If reduction fails or signs of ischemia present, proceed to urgent surgical treatment 1

3. Surgical Approach Selection

For patients without peritonitis or hemodynamic instability:

• Decision between abdominal and perineal procedures should be based on:
  • Patient characteristics (age, comorbidities)
  • Surgeon's expertise 1, 2

Abdominal Approach:

• Preferred for younger, fit patients 2
• Options include:
  • Suture rectopexy
  • Mesh rectopexy
  • Resection rectopexy (better for patients with constipation) 2
• Laparoscopic approach can be considered if surgeon has expertise and patient is stable 1, 2

Perineal Approach:

• Better suited for elderly or high-risk patients 2
• Options include:
  • Altemeier's procedure (perineal proctosigmoidectomy) - particularly indicated for irreducible or strangulated prolapse 2
  • Delorme's procedure (mucosal sleeve resection)
  • Thiersch procedure (anal encirclement) for very high-risk patients 2

Special Considerations

• In cases with signs of ischemia/gangrene, urgent perineal approach (Altemeier's procedure) is indicated 2
• When performing resectional surgery, decision between primary anastomosis (with/without diverting ostomy) and terminal colostomy should be based on patient's clinical condition and risk of anastomotic leakage 1
• Administer appropriate antimicrobial coverage, especially with strangulated prolapse 1

Pitfalls and Caveats

• Do not delay surgical management in unstable patients to attempt conservative measures 1
• Digital rectal examination is essential but should be performed cautiously to avoid exacerbating bleeding
• Rectal bleeding with prolapse may sometimes mask more serious conditions like anal cancer, requiring careful assessment 3
• Division of lateral ligaments during surgery is associated with higher rates of postoperative constipation 2
• Avoid bowel resection in patients with pre-existing diarrhea or incontinence 2

Prompt recognition and appropriate surgical management of rectal prolapse with active bleeding is critical to prevent further complications and improve patient outcomes.