Spontaneous perforation of the rectum presenting as fetal ascites is an extremely rare occurrence. We report the case of an infant where antenatally detected fetal ascites was attributable to intraperitoneal rectal perforation. Investigations directed to identify common causes of this condition did not reveal any aetiology. Patient underwent surgical colostomy formation on day two of life, which was reversed at six weeks of age. We suggest that meconium ascites and peritonitis should be considered as differential diagnoses in fetuses with ascites and, if the neonate requires a laparotomy, the rectal area should be thoroughly inspected to exclude this entity

Arunachalam, Pavai

Balasubramanian, Karthik

Chandran, Radhiga

Ramakrishnan, Santhanakrishnan

Subbarayan, Kalpana

English

Atharva Scientific Publications (E-Jounals)

Ramakrishnan S et al                                           Intraperitoneal rectal perforation 
Vol 2 Issue 1 Jan – Mar 2016                                                               Indian J Case Reports / 8 
Case Report 
Intraperitoneal rectal perforation presenting as fetal ascites – a rare 
occurrence 
Santhanakrishnan Ramakrishnan,
 
Pavai Arunachalam
1
, Kalpana Subbarayan, Radhiga Chandran,
 
Karthik Balasubramanian 
From, Womens Center Hospitals, Coimbatore and 1PSG Institute of Medical Sciences and Research, Coimbatore, India 
Correspondence to:  Dr S Ramakrishnan, Head of the Department and Consultant Neonatologist, Womens Center Hospitals, 
146 B, Mettupalayam Road, Coimbatore – 641043, India. Email: ramkris@mac.com 
Received: 23 December 2015   Initial Review: 27 January 2016    Accepted: 08 February 2016   Published Online: 20 February 2016 
ABSTRACT 
Spontaneous perforation of the rectum presenting as fetal ascites is an extremely rare occurrence. We report the case of an 
infant where antenatally detected fetal ascites was attributable to intraperitoneal rectal perforation. Investigations directed to 
identify common causes of this condition did not reveal any aetiology. Patient underwent surgical colostomy formation on day 
two of life, which was reversed at six weeks of age. We suggest that meconium ascites and peritonitis should be considered as 
differential diagnoses in fetuses with ascites and, if the neonate requires a laparotomy, the rectal area should be thoroughly 
inspected to exclude this entity.  
Key words: Fetal ascites, Intraperitoneal perforation, Neonates, Rectal perforation 
ntestinal perforation is a recognized complication 
during neonatal period [1]. Most commonly, it is 
spontaneous (idiopathic) or following necrotizing 
enterocolitis [2–4].  Perforation most commonly occurs in 
small intestine; however, idiopathic rectal perforation is 
very rare [3]. We report an infant with intraperitoneal 
rectal perforation presenting as antenatally detected 
polyhydramnios and fetal ascites. The cause of perforation 
remains unknown. To our knowledge, this may be only the 
second case reported in English literature [5]. 
CASE REPORT 
A 30 year old second gravida with one previous live child 
presented at 35 weeks gestation with antenatal ultrasound 
showing polyhydramnios (amniotic fluid index 35). There 
was fetal ascites with internal echoes suggestive of 
meconium ascites (Figure I). Anomaly scan performed at 
21 weeks was normal. There was no maternal history of 
diabetes mellitus or hypertension. A full term male baby 
was delivered at 37 weeks by elective caesarian section 
due to worsening polyhydramnios. The baby did not 
require resuscitation at birth. He weighed 4.29 kg, had 
abdominal distension and bilateral large hydroceles. No 
other abnormalities were found. Examination of the 
anorectal region was normal.  
Initial abdominal X-ray on day 1, showed fluid filled 
abdomen with centrally placed bowel loops and paucity of 
bowel gas, suggestive of ascites. There was evidence of 
abdominal calcification. An ultrasound of the abdomen 
revealed the presence of ascites with bilateral hydroceles. 
Bowel loops were visible in the proximal part of the right 
scrotum. The renal system was normal. An 
echocardiography ruled out pericardial effusion. A chest 
X-ray and ultrasound thorax ruled out pleural effusion.  
A diagnostic ascitic tap ruled out infective, urinary, 
biliary and chylous ascites. Usually, a diagnostic ascitic 
tap identifies the presence of bile in the peritoneal fluid. 
I 
Ramakrishnan S et al                                           Intraperitoneal rectal perforation 
Vol 2 Issue 1 Jan – Mar 2016                                                               Indian J Case Reports / 9 
      
Figures: Fig 1 – Antenatal ultrasound scan of fetus demonstrating ascites with internal echoes (white arrows). Fig 2 – X-ray 
abdomen demonstrating free abdominal air, gas under the diaphragm and prominent falciform ligament, features consistent with 
intestinal perforation. Fig 3 – X-ray of the scrotal region demonstrating enlarged fluid filled scrotal sac with specs of calcification. 
However, loculated and self-sealed antenatal 
perforations may not reveal evidence of bile in the 
peritoneal fluid. The baby had worsening abdominal 
distension and a rising CRP. A repeat abdominal X-ray on 
day 2 showed classical evidence of intestinal perforation 
(Figure II). Scrotal region revealed calcification (Figure 
III). The baby underwent exploratory laparotomy due to 
radiological evidence of perforation.  
Laparotomy demonstrated the presence of a 
considerable amount of meconium and pneumoperitoneum 
from an intraperitoneal rectal perforation. As the upper 
third of the rectum is an intraperitoneal organ, an antenatal 
perforation would have accounted for fetal ascites. No 
other gastrointestinal surgical pathology was identified at 
laparotomy. A thorough intraperitoneal wash was given. 
Baby underwent a divided colostomy. The child was stable 
post-operatively; the ascites regressed and the stoma 
started functioning on the first post-operative day. A rectal 
biopsy showed the presence of normal ganglion cells 
ruling out Hirschsprung’s disease. 
Serological investigations excluded causes of infective 
ascites such as Syphilis, Toxoplasma, Cytomegalovirus, 
Rubella, Herpes Simplex and Parvovirus B19. A direct 
Coomb’s test was negative. He was neither anaemic nor 
jaundiced. A newborn blood spot test ruled out congenital 
hypothyroidism and cystic fibrosis. A contrast enema 
performed prior to colostomy reversal was normal. The 
child underwent colostomy reversal at 6 weeks of life. On 
last follow up, child was two years and eleven months old, 
and he was thriving well with normal developmental 
milestones and no further abdominal concerns.  
DISCUSSION 
Accumulation of fluid in the fetal abdominal cavity may be 
due to chylous ascites [6], urinary, biliary, and pancreatic 
ascites, ruptured ovarian cyst, chemical or bacterial 
peritonitis, anorectal malformations [7], cardiac ascites, 
pulmonary, infectious and metabolic ascites [8]. 
Sometimes the cause of ascites may not be ascertained 
(idiopathic ascites) [8]. Extrusion of sterile meconium 
from fetal gut into the peritoneal cavity may result in 
sterile meconium ascites and peritonitis. In the majority of 
cases, it is caused by intestinal perforation secondary to 
bowel obstruction or meconium ileus [9]. Small bowel, 
particularly distal ileum, is the most commonly affected 
part and prenatal perforation of the rectum is extremely 
rare [10]. Less common causes of meconium peritonitis 
include volvulus, imperforate anus and meconium plugs.  
Pitcher et al [11] reported nine babies with fetal 
extraperitoneal rectal perforation presenting at or soon 
after birth. These babies presented with cystic mass in the 
perineum. They reported a good outcome when identified 
and managed appropriately. Casaccia et al [10] reported 
the first case of intraperitoneal fetal rectal perforation that 
presented as isolated ascites without any associated mass 
in the perineum. The authors described the fetal ascitic 
fluid as hyperechoic suggestive of possible fetal intestinal 
perforation. Postnatal ultrasound had confirmed the 
presence of neonatal ascites with floating echogenic 
material. The authors identified localized rectal perforation 
and a considerable amount of intra-abdominal fluid with 
meconium at laparotomy. To our knowledge, no further 
cases of fetal ascites and meconium peritonitis secondary 
to intraperitoneal rectal perforation have been reported. 
Ramakrishnan S et al                                           Intraperitoneal rectal perforation 
Vol 2 Issue 1 Jan – Mar 2016                                                               Indian J Case Reports / 10 
Fines et al [12] reported prenatal sigmoid perforation 
secondary to amniocentesis. In our case, the mother did not 
undergo amniocentesis. Rectal examination, rectal 
thermometers and rectally administered medications may 
cause neonatal rectal perforation [13]. However, this baby 
did not undergo any of the above procedures and 
underwent only a right iliac fossa ascitic tap, which could 
not have caused the rectal perforation. In our case, the 
exact etiology of the rectal perforation is unknown, and we 
postulate that this is a case of an idiopathic intraperitoneal 
rectal perforation that manifested as fetal ascites.  
This baby’s initial abdominal X-ray did not reveal any 
clear evidence of intestinal perforation. Initial X-ray 
showed centrally placed bowel loops with a paucity of 
bowel gas suggestive of fluid filled abdomen. A 
subsequent X-ray revealed the classical “Foot Ball” sign 
suggestive of intestinal perforation. Abdominal X-ray 
performed early in the neonatal period may not have 
allowed air to fill the entire gut and may not identify a 
perforation, thus delaying prompt diagnosis and surgical 
intervention [14]. Gillies et al [15] also highlighted this in 
their case report. Passage of meconium through a 
persistent processus vaginalis might have contributed to 
the calcifications seen in the scrotum, in our case. This is a 
recognised finding in meconium peritonitis [16]. 
CONCLUSION 
Meconium peritonitis should be considered where 
hyperechoic fetal ascites is present. At laparotomy, if no 
other site of perforation is evident, a thorough inspection 
of the rectal area must be performed to identify this rare 
cause of fetal ascites. Key investigations to identify cause 
of rectal perforation must be carried out. Of note, 
abdominal X-ray performed within few hours of birth may 
not reveal evidence of perforation. By repeating an 
abdominal X-ray after few hours, or by performing serial 
X-rays, there would be sufficient time for the bowel loops 
to fill with air enabling easy detection of perforation 
REFERENCES 
1. Tan CE, Kiely EM, Agrawal M, Brereton RJ, Spitz L. 
Neonatal gastrointestinal perforation. J Pediatr Surg. 
1989; 24: 888–92.  
2. Kawase Y, Ishii T, Arai H, Uga N. Gastrointestinal 
perforation in very low-birth weight infants. Pediatr Int. 
2006; 48: 599–603.  
3. Grosfeld JL, Molinari F, Chaet M, Engum SA, West KW, 
Rescorla FJ, et al. Gastrointestinal perforation and 
peritonitis in infants and children: Experience with 179 
cases over ten years. Surgery. 1996; 120(4): 650–6. 
4. Zamir O, Shapira SC, Udassin R, Peleg O, Arad I, Nissan 
S. Gastrointestinal perforations in the neonatal period. Am 
J Perinatol. 1988; 5: 131–3.  
5. Sundararajan L, Patel D, Jawaheer G. Antenatal rectal 
perforation presenting in the neonate. Pediatr Surg Int. 
2008;24:601-3.  
6. Cochran WJ, Klish WJ, Brown MR, Lyons JM, Curtis T. 
Chylous ascites in infants and children: a case report and 
literature review. J Pediatr Gastroenterol Nutr. 
1985;4:668-73. 
7. Hoffman C. Fetal ascites. Arch Pediatr Adolesc Med. 1951; 
82(1): 28. 
8. Favre R, Dreux S, Dommergues M, Dumez Y, Luton D, 
Oury J-F, et al. Nonimmune fetal ascites: A series of 79 
cases. Am J Obstet Gynecol. 2004; 190(2): 407–12.  
9. Bell MJ. Peritonitis in the newborn--current concepts. 
Pediatr Clin North Am. 1985; 32: 1181–201.  
10. Casaccia G, Giorlandino C, Catalano OA, Bagolan P. 
Prenatal rectal perforation: an unsuspected cause of 
isolated ascites. J Perinatol. 2006; 26(11): 717–9. 
11. Pitcher GJ, Davies MR, Bowley DM, Numanoglu A, 
Rode H. Fetal extraperitoneal rectal perforation: a rare 
neonatal emergency. J Pediatr Surg. 2009; 44: 1405–9.  
12. Fines B, Ben-Ami TE, Yousefzadeh DK. Traumatic 
prenatal sigmoid perforation due to amniocentesis. Pediatr 
Radiol. 2001; 31(6): 440–3.  
13. Frank JD, Brown S. Thermometers and rectal perforations 
in the neonate. Arch Dis Child. 1978; 53(10): 824–5.  
14. Veyrac C, Baud C, Prodhomme O, Saguintaah M, 
Couture A. US assessment of neonatal bowel (necrotizing 
enterocolitis excluded). Pediatr Radiol. 2012;42:S107–14. 
15. Gillies MJ, Chowdhury MM, Lakhoo K. A pitfall in the 
interpretation of plain abdnominal radiographs in neonatal 
intestinal perforation. J Med Case Rep. 2008;2: 335.  
16. Berrocal T, Lamas M, Gutieérrez J, Torres I, Prieto C, del 
Hoyo ML. Congenital anomalies of the small intestine, 
colon, and rectum. Radiographics. 1999; 19: 1219–36.
 
How to cite this article: Ramakrishnan S,
 
Arunachalam P, 
Subbarayan K, Chandran R, Balasubramanian K. 
Intraperitoneal rectal perforation presenting as fetal ascites 
– a rare occurrence. Indian J Case Reports. 2016; 2(1):8-10. 
Conflict of interest: None stated, Funding: Nil 


Intraperitoneal rectal perforation presenting as fetal ascites – a rare occurrence

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Intraperitoneal rectal perforation presenting as fetal ascites – a rare occurrence

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