Recurrent Rectal Prolapse Successfully Treated With Polyethylene Glycol.
Recurrent Rectal Prolapse Successfully Treated With Polyethylene Glycol.
复制标题
DOI：
10.1097/pg9.0000000000000380
复制
发表时间：
2023-11
期刊：
影响因子：
--
通讯作者：
中科院分区：
文献类型：
--
作者：
一名原本健康的 18 个月大男性因直肠脱垂到急诊科就诊。父母同意持续两个月的间歇性、恶化的直肠膨出。历史上因每天消耗 32 盎司牛奶而闻名。患者每日大便正常，饮食良好，体重适当增加。在急诊室进行了成功的手动复位。患者出院时每天服用 4.25 g 聚乙二醇 (PEG)。每天 PEG 后脱垂有所改善。然而，停用 PEG 后，脱垂又复发，且明显变大且更难复位（图 1 和图 2）。鉴于脱垂情况恶化，小儿外科在镇静状态下使用柔性乙状结肠镜进行了重复的手动复位。该手术是有效的，没有看到息肉或引线点。手术过程中未获得活组织检查。麻醉下手动复位后，患者坚持每天 17 克 PEG 的治疗方案。没有发生进一步的脱垂复发。直肠脱垂分为部分/粘膜或完全脱垂 (1)。我们的患者患有后者，涉及全层直肠壁挤压。诱发因素包括慢性便秘（最常见）、肠蠕动增加、乳糜泻和囊性纤维化 (1-3)。此外，有病例报告强调了牛奶蛋白过敏和慢性便秘之间的关系，这可能需要进一步考虑减少和/或消除饮食中的牛奶 (4)。由于该患者的脱垂很可能是继发于牛奶摄入过多的便秘，因此没有进行额外的检查。一般来说，直肠脱垂的治疗包括（1）如果没有发生瞬时自发复位，则立即手动复位；（2）便秘肠道疗法。对于大多数儿童来说，直肠脱垂仅通过肠道疗法即可解决。目前尚无明确的手术指征，但如果保守治疗后脱垂仍然存在，或者手法复位有困难，则可以考虑手术(1-3, 5)。
A previously healthy 18-month-old male presented to the emergency department for rectal prolapse. Parents endorsed 2 months of intermittent, worsening rectal bulging. History is notable for the daily consumption of 32 ounces of milk. The patient was stooling daily, eating and drinking well, and gaining weight appropriately. The successful manual reduction was administered in the ED. The patient was discharged on daily polyethylene glycol (PEG) 4.25 g daily. Prolapse improved on daily PEG. However, after PEG discontinuation, prolapse returned, significantly larger and more difficult to reduce (Figs. 1 and 2). Given the worsening prolapse, pediatric surgery performed a repeat manual reduction under sedation with flexible sigmoidoscopy. The procedure was effective, and no polyps or lead points were visualized. No biopsies were obtained during the procedure. After this manual reduction under anesthesia, the patient was adherent to a regimen of 17 g of PEG daily. No further prolapse recurrences occurred.Rectal prolapse is classified as partial/mucosal or complete prolapse (1). Our patient had the latter, which involves full-thickness rectal wall extrusion. Predisposing conditions include chronic constipation (most common), increased bowel motility, celiac disease, and cystic fibrosis (1–3). Additionally, there are case reports highlighting the relationship between cow’s milk protein allergy and chronic constipation, which may warrant further consideration for the reduction and/or elimination of cow’s milk in the diet (4). Since our patient’s prolapse was most likely secondary to constipation with excessive milk intake, an additional workup was not performed. In general, management for rectal prolapse involves (1) immediate manual reduction if instantaneous spontaneous reduction does not occur and (2) constipation bowel regimens. For most children, rectal prolapse resolves with a bowel regimen alone. There are no definitive indications for surgery, but it can be considered if prolapse persists despite conservative therapy or if there is difficulty in manual reduction (1–3, 5).