Difference between revisions of "Rectal foreign body"

(Text replacement - "==Diagnosis==" to "==Evaluation==")
(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==
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*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)
***Perf of rectum below peritoneal reflection shows extraperitoneal air along psoas
+
***Perforation of rectum below peritoneal reflection shows extraperitoneal air along psoas
***Perf above peritoneal reflection reveals intraperitoneal free air under diaphragm  
+
***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==
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==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

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

  1. 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.
  2. 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

  1. Coskun, A. et al. Management of Rectal Foreign Bodies. World J Emerg Surg. 2013; 8:11.