Rectal foreign body: Difference between revisions
Neil.m.young (talk | contribs) (Text replacement - "==Diagnosis==" to "==Evaluation==") |
Devin Smith (talk | contribs) (Added potential position for removal, method of removal, use of anoscope, and rec'd considering sigmoidoscope post procedure) |
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*Make sure that object is not sharp before exam | *Make sure that object is not sharp before exam | ||
*Injuries may consist of hematoma, lacerations (with potential perforation) | *Injuries may consist of hematoma, lacerations (with potential perforation) | ||
*Patients often do not present immediately; this prolonged retention increases the chances of complication | |||
==Clinical Features== | ==Clinical Features== | ||
| Line 7: | Line 8: | ||
*History of rectal foreign body placement | *History of rectal foreign body placement | ||
*Most are in the rectal ampulla and therefore palpable on digital examination | *Most are in the rectal ampulla and therefore palpable on digital examination | ||
*Rectal bleeding | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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**Demonstrate position, shapes, and number of foreign bodies | **Demonstrate position, shapes, and number of foreign bodies | ||
**Demonstrates possible presence of free air (perforation of rectum or colon) | **Demonstrates possible presence of free air (perforation of rectum or colon) | ||
*** | ***Perforation of rectum below peritoneal reflection shows extraperitoneal air along psoas | ||
*** | ***Perforation above peritoneal reflection reveals intraperitoneal free air under diaphragm | ||
*CT | *CT | ||
**Useful when foreign body is radiolucent and for detection of free air | **Useful when foreign body is radiolucent and for detection of free air | ||
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#*Anal lubrication | #*Anal lubrication | ||
#*In lithotomy position, suprapubic pressure with DRE and valsalva may deliver object without instrumentation. | #*In lithotomy position, suprapubic pressure with DRE and valsalva may deliver object without instrumentation. | ||
#*May also attempt removal in prone knee-to-chest position with the patient bearing down | |||
#*Anoscope utilization and direct lighting will often improve visualization of the object if low lying | |||
#*If obstetric forceps needed, patient should bear down as object is extracted. | #*If obstetric forceps needed, patient should bear down as object is extracted. | ||
#*Large bulbar objects create a vacuum-like effect | #*Large bulbar objects create a vacuum-like effect | ||
#**Break vacuum by passing foley behind object, inject air and pull foley out (balloon up) | #**Break vacuum by passing foley behind object, inject air and pull foley out (balloon up) | ||
#**Can introduce multiple foley catheters from different angles beyond the object, inflate the balloons, and slowly retract the foleys - using the force to help extract the object. | |||
===Surgical Consultation Indications=== | ===Surgical Consultation Indications=== | ||
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*ED attempts fail | *ED attempts fail | ||
*Risk of ischemia, perforation, or if excess manipulation required (risk of bacteremia) | *Risk of ischemia, perforation, or if excess manipulation required (risk of bacteremia) | ||
===Consider Gastroenterology Consultation=== | |||
*Can consider requesting sigmoidoscopy after object removal to rule out mucosal lacerations or small perforations not seen on radiographs<ref>Coskun, A. et al. Management of Rectal Foreign Bodies. World J Emerg Surg. 2013; 8:11.</ref> | |||
**This is a concern in prolonged retention, objects with sharp corners, or toxic appearing patients | |||
==Disposition== | ==Disposition== | ||
| Line 47: | Line 56: | ||
==References== | ==References== | ||
<references/> | |||
[[Category:GI]] | [[Category:GI]] | ||
Revision as of 01:56, 6 February 2017
Background
- Make sure that object is not sharp before exam
- Injuries may consist of hematoma, lacerations (with potential perforation)
- Patients often do not present immediately; this prolonged retention increases the chances of complication
Clinical Features
- Rectal pain and/or fullness
- History of rectal foreign body placement
- Most are in the rectal ampulla and therefore palpable on digital examination
- Rectal bleeding
Differential Diagnosis
Anorectal Disorders
- Anal fissure
- Anal fistula
- Anal malignancy
- Anal tags
- Anorectal abscess
- Coccydynia
- Colorectal malignancy
- Condyloma acuminata
- Constipation
- Crohn's disease
- Cryptitis
- GC/Chlamydia
- Fecal impaction
- Hemorrhoids
- Levator ani syndrome
- Pedunculated polyp
- Pilonidal cyst
- Proctalgia fugax
- Proctitis
- Pruritus ani
- Enterobius (pinworms)
- Rectal foreign body
- Rectal prolapse
- Syphilitic fissure
Non-GI Look-a-Likes
Evaluation
Foreign body noted in rectum on lateral abdominal xray
- Abdominal xray
- Demonstrate position, shapes, and number of foreign bodies
- Demonstrates possible presence of free air (perforation of rectum or colon)
- Perforation of rectum below peritoneal reflection shows extraperitoneal air along psoas
- Perforation above peritoneal reflection reveals intraperitoneal free air under diaphragm
- CT
- Useful when foreign body is radiolucent and for detection of free air
Management
ED removal
Suitable for non-sharp objects that are in the distal rectum
- Sedation
- IV sedation and analgesia usually needed for adequate relaxation for removal of larger FB's
- Local anesthesia (perianal block) will relax the anal sphincter and may be needed.
- Manual removal
- Anal lubrication
- In lithotomy position, suprapubic pressure with DRE and valsalva may deliver object without instrumentation.
- May also attempt removal in prone knee-to-chest position with the patient bearing down
- Anoscope utilization and direct lighting will often improve visualization of the object if low lying
- If obstetric forceps needed, patient should bear down as object is extracted.
- Large bulbar objects create a vacuum-like effect
- Break vacuum by passing foley behind object, inject air and pull foley out (balloon up)
- Can introduce multiple foley catheters from different angles beyond the object, inflate the balloons, and slowly retract the foleys - using the force to help extract the object.
Surgical Consultation Indications
- Removal could injure the sphincter
- ED attempts fail
- Risk of ischemia, perforation, or if excess manipulation required (risk of bacteremia)
Consider Gastroenterology Consultation
- Can consider requesting sigmoidoscopy after object removal to rule out mucosal lacerations or small perforations not seen on radiographs[1]
- This is a concern in prolonged retention, objects with sharp corners, or toxic appearing patients
Disposition
- Consider observation for at least 12hr if concern for rectal perforation
See Also
References
- ↑ Coskun, A. et al. Management of Rectal Foreign Bodies. World J Emerg Surg. 2013; 8:11.