SMALL BOWEL PROLAPSE THROUGHTHE VAGINA (CLINICAL CASE REPORT)
mall bowel prolapse through the vagina is a very rare,life-threatening condition that requires urgent diagnosis anddamage control by small bowel reduction due to the risk ofischemia and subsequent necrosis . The calculated inci-dence is 0.03-1,2% after surgical manipulations adjacent tothe upper vagina (hysterectomy, surgery to remove the cer-vix of the uterus, upper vaginectomy). Predisposing risk fac-tors include hypo-estrogenic state in post-menopausal fe-males, vaginal prolapse, past vaginal surgery, old age, en-terocele, history of pelvic radiation. Other risk factors areexpanded intraabdominal pressure with ascites, obstruction,and expanded episodes of coughing .After radiotherapy, the development of progressive oblit-erative endarteritis causes hypoxia and ischemic changes.Ultimately, it can be the reason for cell and tissue atrophy.This usually occurs with a high total radiation dose or as aresult of direct toxicity of radiation .There are a few conditions that might contribute to thefault of the vaginal fornix after vaginal or abdominal surgery:poor surgical technique, postoperative complications (suchas contamination), resumption of sexual activity prior to re-covery, chronic steroid treatment, hyponatremia, low vita-min levels, perineal proctectomy. Additionally, several otherreasons should be kept in mind: ineffectively controlled dia-betes, renal failure, chemotherapy, and insufficient tissueoxygenation due to pulmonary disease . The etiologyof the protrusion of the contents of the abdominal cavityinto the vagina is not exactly established, but an importantfactor is increasing of intra-abdominal pressure. An abruptrupture of the vaginal fornix is related to a significant lack ofelasticity of the peritoneum, fascia and vaginal mucosa .The most commonly prolapsed organ is the distal ileum,among other organs that may protrude through the vaginaare: omentum, fallopian tube and appendix. Early interven-tion is essential, as up to 33% of small bowel protrusionthrough vagina might be complicated by bowel ischemia . Manifestation often includes signs of small bowel ob-struction and herniated small bowel loops can be directlyseen in the vaginal fornix (often presented with large loopsof the small bowel). Usually, patients complain of abdominal,pelvic, or vaginal pain, vaginal bleeding, and the sensationof a bulge in the vagina. Small bowel evisceration throughthe vagina is associated with a 6-8% risk of mortality .The most important step of early management requiresan attempt to gently reduce the bowel into the peritonealcavity and pack the vagina with moistened gauze. If the bowelis unable to be reduced, it should be covered with moistgauze before definitive surgery . No agreement existsin regards to the ideal methodology for surgical repair. Trans-abdominal, transvaginal, laparoscopic and combined waysof management have been reported. The essential parts ofrepair combine examination of the whole length of the smallbowel and mesentery, lavage of the peritoneal cavity, andrepair of the vaginal vault.Complications include smallbowel ischemia with necrosis requiring resection, develop-ment of sepsis, systemic inflammatory response syndrome(SIRS) because of bowel necrosis, and death.