Spontaneous scrotal faecal fistula in infant: A case report and literature reviewCorrespondence Address :
Dr. Rajendra K Ghritlaharey, Associate Professor, Department of Pediatric Surgery, Gandhi Medical College & Associated Kamla Nehru & Hamidia Hospitals Bhopal, M. P. 462 001 INDIA. E-mail - firstname.lastname@example.org
A one month old infant presented with an irreducible right inguino-scrotal swelling and faecal discharge from the scrotum for a week. Inguinal exploration revealed an incarcerated right inguinal hernia containing loop of small intestine, Meckelâ€™s diverticulum and a perforation of the small intestine measuring 3 cm. Resection of part of ileum containing the diverticulum and perforation was done and endâ€“ toâ€“end anastomosis was performed. Spontaneous intestinal - scrotal fistula from incarcerated inguinal hernia in neonates and infants is a rare occurrence and hitherto only seven such cases have been reported in the world literature.
Incarcerated inguinal hernia, neonates, scrotal faecal fistula
Inguinal hernia repair is one of the most common general neonatal and paediatric operations. The reported incidence of inguinal hernia varies from 0.8% to 4.4% in children(1). The risk of incarceration of inguinal hernia in children varies between 5 to 23.6%, the highest reported being 60% in the first 6 months of life. The risk of strangulation following incarcerated inguinal hernia in infants is very low and ranges between 0 to 1.8% [2, 3]. On rare occasion incarcerated bowel can perforate leading to formation of enteroâ€“scrotal cutaneous fistula. In this paper a case of enteroâ€“scrotal cutaneous fistula is described and the literature reviewed.
A one-month-old boy was admitted to hospital with a chief complaint of persistent swelling at the right inguino-scrotal area and discharging faeces from the scrotum for a week. He was a first of a set of twins born at term normally at hospital and his postnatal condition was good. His mother noticed a reducible right inguino-scrotal swelling since birth. However he did very well until a week before admission when mother noticed that it was irreducible and discharging faeces from scrotum. He also had associated vomiting, feeds refusal and had not passed motion, cough and cold for which he was treated at primary health centre for three days before admission.
Examination revealed that he was 2.25 kg, ill, dehydrated and his abdomen was mildly distended without visible loops of bowels. At admission, he was hypothermic, peripheral cyanosis and scleraema were also noticed. An irreducible right inguinal hernia was noted with gangrene of the right scrotum. Faecal matter was seen discharging from the scrotum (Table/Fig 1). The left inguino-scrotal area was normal. Examination of other systems did not demonstrate any abnormality.
Routine laboratory investigations gave the following results; Hb-10gm% (needed blood transfusion), total and differential WBC counts was 9800/cmm, P 78, L 20, M 02, B 00. His serum electrolyte was; Na â€“131.2 mmol/L, K â€“ 3.4 mmol/L. C-Reactive protein was not done. Blood culture showed heavy growth of pseudomonas species. Gas shadow was seen at the right inguinal region and the right scrotum on plain radiograph of the abdomen and pelvis. There was no evidence of free air on the radiograph (Table/Fig 2).
Exploration of the inguinal canal under general anaesthesia was carried out after initial stabilization of the patient and this revealed an inguino scrotal hernia containing a loop of intestine and Meckelâ€™s diverticulum. A perforation at the ante-mesenteric border 6 cm proximal to the Meckelâ€™s diverticulum was observed (Table/Fig 3). Resection of part of ileum containing the perforation and diverticulum was performed and end-to-end anastomosis was made. The right testicle appeared normal. Herniotomy and debridement of the scrotal skin was also done and the scrotal skin closed with a drain. He received a combination of ceftriaxone + tazobactam, amikacin, and metronidazole to which ampiclox was added on fourth postoperative day. His general condition did not improve much after operation; his scleraema persisted, developed pneumonitis and unfortunately died of septicaemia on the fifth postoperative day.
Congenital inguinal hernia is one of the commonest surgical conditions in children. Congenital inguinal hernia in children is a result of the failure of the processes vaginalis to obliterate. Boys are 10 to 12 times more affected than girls. It is also reported more frequently in premature. The risk of incarceration has been reported to be as high as 60% in the first 6 months of life(3). Perforation of the intestine through the scrotal wall of incarcerated inguinal hernia is extremely rare and only seven such cases has been reported in the world literature till date(2),[4-8]. Summary of above cases are given in (Table/Fig 4). This complication appears to occur only in developing countries (India and Nigeria) and was due to late presentation, including our case.
Out of eight cases (including our) of spontaneous entero-scrotal faecal fistula in neonates and infants, there were right side involvement in seven and only one patient had left side presentation. This is because of predominance of right-sided inguinal hernia in children. The ipsilateral testis is always at risk of ischemia / necrosis because of compression of the spermatic card structures by the strangulated / incarcerated inguinal hernia. In review of eight cases including our; at two occasion orchidectomy was needed (4),(5). Morbidity of incarcerated and strangulated inguinal hernia in newborn is high with an attended risk of bowel gangrene and testicular infaction.
The preferred and gold standard management of incarcerated inguinal hernia in children without evidence of strangulation is non-operative reduction under analgesia and sedation followed by an elective planned herniotomy after 48 â€“ 72 hrs. When strangulation is present, surgery is mandatory to avoid septicaemia, even in patients decompressing intestine through scrotal fistula. The principle of early referral and repair of inguinal hernias should be encouraged to avoid morbidity and possible avoidable mortality(7),(9),(10).
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