Spontaneous Faecal Fistula A Rare Presentation Of Inguinal Hernia
J Ayub Med Col Abbottabad 2005;17(4)
CASE REPORT
SPONTANEOUS FECAL FISTULA: A RARE PRESENTATION OF
INGUINAL HERNIA
Abdul Samad, Gul Muhammad Sheikh
Department of Surgery, Isra University Hospital, Hyderabad
A 25 years old young man presented with the right scrotal and supra-pubic fecal fistulae due to the
spontaneous bursting of a congenital inguinal hernia. This hernia remained obstructed and
strangulated for about ten days before getting ruptured. Resection and end to end anastomosis of
involved ileum was done. The literature search could reveal only five such cases in pediatric age
group and this complication is considered to be much rarer among the adult population. This case
report is being presented here in view of the extreme rarity of this complication in the adult age
group.
Keywords: Inguinal hernia, Congenital, Spontaneous, Fecal fistula, Incarcerated hernia
INTRODUCTION
but he continued to have discharge of fecal material
from scrotum as well as the supra-pubic region.
The congenital inguinal hernia is a common
Therefore he was brought to the emergency
condition encountered in the general surgical
room of Isra University Hospital, Hyderabad in a
practice. This condition is usually diagnosed and
severely malnourished state and fecal material
operated upon during the early years of life.
coming out from scrotum as well as supra-pubic
Sometimes, these patients do not consult the
region. His nutritional status was improved by
physician and remain undiagnosed for a long time.
parenteral nutrition supplementation pre-operatively.
Even when they are diagnosed, some of these patients
Barium enema showed the cut-off point at the level
delay the surgical procedure due to the financial
of distal ileum and barium was seen coming out
constraints. Many complications have been observed
through the scrotum. So, the patient underwent
in this regard due to the delay in diagnosis and
exploratory laparotomy which revealed distal ileum
treatment. The most common serious complication is
(about 12 cms proximal to ileocaecal junction) stuck
incarceration and strangulation. Spontaneous
in the deep inguinal ring. The scrotal and supra-pubic
perforation of the intestine through the scrotal wall in
wounds were found communicating with each other
an incarcerated inguinal hernia is an extremely rare
and two ends of the ileum were opening into the
complication. In view of the extreme rarity of this
inguinal canal. The two ends of ileum were retrieved
complication, a case report pertaining to spontaneous
from the deep inguinal ring, margins were refreshed
scrotal fecal fistula secondary to the inguinal hernia
and two layered end to end anastomosis was done.
in an adult is being presented here.
Deep inguinal ring was closed from inside of the
CASE REPORT
peritoneal cavity. The communicating tract of supra-
pubic and scrotal wounds was laid open. Both scrotal
This is the case report of a 25 years old young
and supra-pubic wounds as well as communicating
fisherman having right sided reducible groin swelling
tract were debrided and managed with daily
since childhood. About three weeks before presenting
dressings. The post-operative recovery and hospital
to our institution, the right sided groin swelling
stay was smooth and uneventful.
became painful and irreducible and was associated
with abdominal pain, bilious vomiting and absolute
DISCUSSION
constipation. At that time, he was working in the
Illiteracy, poverty and non-availability of proper
distant waters and was brought to a traditional healer
medical care are the major factors having potential
(Quack) after few days. He was given various oral
for transformation of a relatively benign condition of
medications which provided only transient pain
inguinal hernia into the complicated state of
relief. After about ten days of agonizing pain,
incarceration and strangulation. It is extremely rare to
vomiting and constipation, his groin swelling got
have progression of strangulation to the development
ruptured through the scrotum and fecal material
of spontaneous fecal fistula. Only five cases of
started to come out through the scrotum. A few hours
spontaneous scrotal fecal fistula in pediatric
later, he developed discharge of fecal material from
population were found to be reported in the world
the supra-pubic region as well. Afterwards, the
literature.1-4 The development of spontaneous scrotal
patient became pain free and vomiting was stopped
fecal fistula secondary to the incarcerated inguinal
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J Ayub Med Col Abbottabad 2005;17(4)
hernia is much rarer among the adult population5 as
compared to the pediatric age group. Most of these
spontaneous fecal fistulae have been reported from
the developing countries like India,1-3, 6 Nigeria4, 5 and
now this first case report from Pakistan. Two fistulae
following spontaneous rupture of strangulated
Richter’s hernia have been reported from Nigeria.5 A
spontaneous small bowel fistula secondary to the
Littre’s femoral hernia was reported from the
developed world (United Kingdom) about 20 years
ago.7
Surgical intervention is regarded as one of
the major causes of development of fecal fistula in
adults.5, 8,9 The use of prosthetic material has been
reported as the cause of fecal fistula in some studies9.
Fig.3: Barium enema showing cut-off point at the
Repeated treatment of scrotal hernia by native doctor
distal ileum
has also been reported as a cause of multiple urinary
and fecal fistulae in one study.8 The incision of hernia
by herbalists as well as intervention by quacks has
been reported as the cause of fecal fistula in adults.5
None of these interventions was observed as a cause
of fecal fistula in our patient.
Fig.4: Ileum stuck in the deep inguinal ring
observed at the time of laparotomy
This case report highlights the need for an
early and accurate diagnosis followed by prompt
treatment of groin swellings. The delay in its
Fig.1: Close up photograph of patient
diagnosis and management may result in various
complications including this rare complication of
spontaneous scrotal fecal fistula. The principle of
early referral and repair of childhood inguinal hernias
is the key for prevention of this complication as well
as the associated morbidity and mortality. The
presentation of congenital inguinal hernia in the form
of this rare complication in adult age also reflects
state of health care in the developing countries. This
unusual and rare complication should be considered
as an eye opener for the concerned authorities to
improve the existing health care system.
REFERENCES
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Gupta DK, Rohatgi M. Inguinal hernia in children: an
Indian experience. Pediatr Surg Int 1993;8: 466-8.
Fig.2:Second close up photograph of patient
2.
Rattan KN, Garg P. Neonatal scrotal faecal fistula.
Pediatr Surg Int. 1998; 13: 440-1.
showing scrotal and supra-pubic sites of fecal
fistulae
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J Ayub Med Col Abbottabad 2005;17(4)
3.
Kasat LS, Waingankar VS, Kamat T, Anilkumar,
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complication of native treatment of inguinal hernia.
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Trop Geogr Med 1991; 43(1-2):105-7.
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Nwabunike TO. Enterocutaneous fistulas in Enugu,
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postoperative complication of laparoscopic inguinal
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_____________________________________________________________________________________________
Address For Correspondence:
Dr. Abdul Samad, Flat. No.8, 4th floor, 339-Bohri Bazar, Saddar, Hyderabad. Phone: 0221-786281
E-mail: abdulsamad@email.com
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