Sclerotherapy for Rectal Prolapse


Rectal prolapse is a relatively common condition in children with a peak incidence between one and three years of age when toilet training is occurring. Male predominance occurs in most cases. Rectal prolapse can be partial when only protrusion of the mucosa from the anal verge occurs, or complete when the full thickness of the rectum prolapses. The cause of rectal prolapse can be anatomic such as a vertical configuration of the sacrum, greater mobility of the sigmoid colon, loose attached rectal mucosa and absence of Houston's valve in most cases. Children with prolapse have lower basal and squeeze pressures during anorectal manometry when compared with normal control. Diagnosis of rectal prolapse is made by physical exam and history. Prolapse of mass, bleeding after defecation, diarrhea, prolapse rectum and constipation are the most common signs and symptoms. Most (> 80%) children with rectal prolapse do not need specific surgical treatment if constipation, parasites and excessive straining are managed. Children that fail medical therapy will eventually need some surgical management. Injection sclerotherapy is the first surgical method used to manage rectal prolapse and is likely to cure the child with one or two injections 80% of the time. Transrectal sclerotherapy is performed with 50% saline solution, ethyl alcohol or cows milk. A volume of 0.50 ml/kg of sclerosant divided over four quadrants appears a prudent volume to managed rectal prolapse. Older scholar children and those overweight are likely to experience recurrence eventually needing an operation. If sclerotherapy fails then the Thiersch procedure is recommended. The Thiersch procedure is a minimally invasive procedure involving placing a suture encircling the anal canal under the skin. The aim is to narrow the relaxed anal sphincter and cause proliferation to form adhesions within the surrounding tissue. If sclerotherapy and Thiersch procedures fail, then other more sophisticated major abdominal or perineal procedure such as stripping of the mucosa or rectopexy should be used.     

References:
1- Zganjer M, Cizmic A, Cigit I, Zupancic B, Bumci I, Popovic L, Kljenak A: Treatment of rectal prolapse in children with cow milk injection sclerotherapy: 30-year experience. World J Gastroenterol. 14(5):737-40, 2008
2- Flum AS, Golladay ES, Teitelbaum DH: Recurrent rectal prolapse following primary surgical treatment. Pediatr Surg Int. 26(4):427-31, 2010
3- Puri B: Rectal prolapse in children: Laparoscopic suture rectopexy is a suitable alternative. J Indian Assoc Pediatr Surg. 15(2):47-9, 2010
4- Sarmast MH, Askarpour S, Peyvasteh M, Javaherizadeh H, Mooghehi-Nezhad M: Rectal prolapse in children: a study of 71 cases. Prz Gastroenterol. 10(2):105-7, 2015
5- Chauhan K, Gan RW, Singh S: Successful treatment of recurrent rectal prolapse using three Thiersch sutures in children. BMJ Case Rep. 2015 Nov 25;2015. pii: bcr2015211947. doi: 10.1136/bcr-2015-211947
6- Dolejs SC, Sheplock J, Vandewalle RJ, Landman MP, Rescorla FJ: Sclerotherapy for the management of rectal prolapse in children.  J Pediatr Surg. 53 (1): 73-76, 2018://dx.doi.org/10.1016/j.jpedsurg.2017.11.015


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