Signs of Strangulation in Rectal Prolapse
Strangulated rectal prolapse presents with signs of bowel ischemia including gangrene or necrosis of the prolapsed tissue, hemodynamic instability, and systemic signs of sepsis—this is a surgical emergency requiring immediate operative intervention. 1
Clinical Recognition of Strangulation
Local Tissue Changes
- Visual inspection reveals gangrenous or necrotic changes in the prolapsed rectal tissue, indicating compromised blood supply and tissue death 1
- The prolapsed segment becomes irreducible and edematous, failing manual reduction attempts even under sedation or anesthesia 1, 2, 3
- Ulceration and perforation may develop on the prolapsed mucosa as complications of prolonged strangulation 1, 4
Systemic Signs of Ischemia
- Hemodynamic instability (hypotension, tachycardia, signs of shock) indicates advanced tissue necrosis with systemic compromise 1
- Leukocytosis is typically present except in immunocompromised patients or those on steroids, serving as a predictor of transmural bowel necrosis 1
- Elevated lactate levels reflect poor tissue perfusion and bowel ischemia, a key marker in severe sepsis and septic shock 1
- Elevated procalcitonin (PCT) correlates significantly with intestinal necrotic damage, degree and extension of tissue damage, and mortality 1
Clinical Presentation Pattern
- Pain becomes prominent in strangulated prolapse, contrasting with uncomplicated rectal prolapse where pain is notably uncommon 5
- Patients may present with lower abdominal pain, constipation, and hematochezia when strangulation develops acutely 1
- Signs of peritonitis (abdominal rigidity, rebound tenderness, guarding) indicate perforation of the strangulated bowel 1
Critical Management Pitfall
Do not delay surgical intervention to perform imaging in hemodynamically unstable patients with strangulated rectal prolapse—timely management takes absolute priority over diagnostic workup 1. In stable patients, contrast-enhanced CT can identify complications such as bowel obstruction, perforation, and peritonitis, but should never delay treatment 1.
Immediate Action Required
- Immediate surgical treatment is mandatory when signs of shock or gangrene/perforation of the prolapsed bowel are present 1
- Abdominal open approach is recommended in hemodynamically unstable patients with complicated rectal prolapse 1
- Non-operative management is contraindicated when strangulation with gangrene or perforation is evident 1