A 76-year-old man is brought from the nursing home to the emergency department for evaluation of rectal discomfort that has worsened over the past 3 days. The patient also had an episode of a small amount of rectal bleeding. His other medical problems include chronic constipation, benign prostatic hypertrophy, and chronic obstructive pulmonary disease. His temperature is 37.2 C (99 F), blood pressure is 110/60 mm Hg, pulse is 100/min, and respirations are 20/min. Examination of the anal area shows a thick, protruding, rectal mucosal mass with bluish discoloration, concentric rings, and friability. He appears to be in moderate distress due to rectal discomfort. Which of the following is the most appropriate next step in the management of this patient?

Question

A 76-year-old man is brought from the nursing home to the emergency department for evaluation of rectal discomfort that has worsened over the past 3 days.  The patient also had an episode of a small amount of rectal bleeding.  His other medical problems include chronic constipation, benign prostatic hypertrophy, and chronic obstructive pulmonary disease.  His temperature is 37.2 C (99 F), blood pressure is 110/60 mm Hg, pulse is 100/min, and respirations are 20/min.  Examination of the anal area shows a thick, protruding, rectal mucosal mass with bluish discoloration, concentric rings, and friability.  He appears to be in moderate distress due to rectal discomfort.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf4e_de0c_8f63_77bd278ea92a_MD0005_00 This patient's presentation suggests complete rectal prolapse with strangulation and gangrene. Rectal prolapse is due to a mucosal or full-thickness layer of rectal tissue sliding through the anal orifice. Risk factors for rectal prolapse include prior pelvic surgery, pelvic floor dysfunction or anatomical defects, conditions causing increased intra-abdominal pressure (eg, chronic straining with constipation, benign prostatic hypertrophy), or women >age 40 with prior vaginal deliveries. Patients usually develop difficulty with defecation, diarrhea/fecal incontinence, discomfort (not significant pain) in the anal area, rectal bleeding, and a protruding rectal mass. Symptoms may occur intermittently. Significant rectal pain suggests a different underlying disorder. Diagnosis is made clinically by physical examination showing a mass extending through the anus with concentric rings of rectal mucosa. Management depends on the extent of prolapse and symptoms: Medical management is usually sufficient for patients without a full thickness rectal prolapse. Uncomplicated prolapsed rectal mucosa can be reduced by gentle digital pressure. Additional therapies include adequate fluid and fiber intake, pelvic floor exercises, and possible biofeedback for fecal incontinence (Choice B). Surgery (intra-abdominal or perineal approach) is preferred for patients who have complete rectal prolapse (such as this patient) or prolapse with fecal incontinence and/or constipation. Untreated complete rectal prolapse can lead to strangulation and gangrene of the rectal mucosa. The prognosis is generally good with prompt and appropriate care. (Choice A) This patient needs prompt treatment and possible emergency surgical intervention in the form of a rectosigmoidectomy. Outpatient medical management is not recommended at this point. (Choice E) Anoscopy is required for diagnosing a prolapsed internal hemorrhoid, which can present as inflamed veins in the left lateral and right anterior/posterior walls of the anal canal. Grade IV internal hemorrhoids can prolapse and usually cannot be reduced. However, internal hemorrhoids do not typically cause a full thickness rectal prolapse with concentric mucosal rings as seen in this patient. Educational objective: Rectal prolapse is due to a mucosal or full-thickness layer of rectal tissue sliding through the anal orifice. Complete rectal prolapse should be promptly evaluated for signs of incarceration and gangrene. Surgery (intra-abdominal or perineal approach) is preferred for patients with complete rectal prolapse or prolapse with fecal incontinence and/or constipation. References: Anorectal conditions: rectal prolapse (http://www.ncbi.nlm.nih.gov/pubmed/24742085) Rectal prolapse (http://www.ncbi.nlm.nih.gov/pubmed/23177071)

A 76-Year-Old Man Is Brought from the Nursing Home to the Emergency