Difference between revisions of "Rectal foreign body"

Line 1: Line 1:
 
==Background==
 
==Background==
 +
*Injuries may consist of hematoma, lacerations, bowel perforation
 +
*Patients often do not present immediately; prolonged retention increases the chances of complication
 
*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)
 
*Patients often do not present immediately; this prolonged retention increases the chances of complication
 
  
 
==Clinical Features==
 
==Clinical Features==
 
*Rectal pain and/or fullness
 
*Rectal pain and/or fullness
 +
*Rectal bleeding
 
*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==
Line 15: Line 15:
 
==Evaluation==
 
==Evaluation==
 
[[File:Rectal_fb.JPG|thumb|Foreign body noted in rectum on lateral [[abdominal xray]]]]
 
[[File:Rectal_fb.JPG|thumb|Foreign body noted in rectum on lateral [[abdominal xray]]]]
 +
 
*[[Abdominal xray]]
 
*[[Abdominal xray]]
**Demonstrate position, shapes, and number of foreign bodies
+
**Demonstrate position, shape, 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 of rectum below peritoneal reflection shows extraperitoneal air along psoas
 
***Perforation 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 small amounts of free air
  
 
==Management==
 
==Management==
 
===ED removal===
 
===ED removal===
 
''Suitable for non-sharp objects that are in the distal rectum''
 
''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===
+
*Consider IV sedation and analgesia for larger foreign bodies
*Removal could injure the sphincter
+
*[[Perianal block]] may be useful to help relax anal sphincter
*ED attempts fail
+
*In lithotomy position, suprapubic pressure with DRE and valsalva may deliver object without instrumentation.
*Risk of ischemia, perforation, or if excess manipulation required (risk of bacteremia)
+
*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 can 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.
  
===Consider Gastroenterology Consultation===
+
===OR Removal===
*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>
+
*Consult surgery for OR removal if:
**This is a concern in prolonged retention, objects with sharp corners, or toxic appearing patients
+
**Size, shape, or location of object has potential to injure anal sphincter during removal
 +
**Attempts at removal in ED fail
 +
**Risk of ischemia, perforation, or if excess manipulation required (risk of bacteremia)
 +
 
 +
===Other Considerations===
 +
*Consider GI consult for sigmoidoscopy after removal<ref>Coskun, A. et al. Management of Rectal Foreign Bodies. World J Emerg Surg. 2013; 8:11.</ref> if:
 +
**Prolonged retention, objects with sharp corners, toxic appearing patients
  
 
==Disposition==
 
==Disposition==
Line 52: Line 52:
  
 
==See Also==
 
==See Also==
*[[Anorectal Disorders]]
+
*[[Anorectal disorders]]
 
*[[Foreign bodies]]
 
*[[Foreign bodies]]
  
 
==References==
 
==References==
 
<references/>
 
<references/>
 +
 
[[Category:GI]]
 
[[Category:GI]]

Revision as of 05:48, 6 February 2017

Background

  • Injuries may consist of hematoma, lacerations, bowel perforation
  • Patients often do not present immediately; prolonged retention increases the chances of complication
  • Make sure that object is not sharp before exam

Clinical Features

  • Rectal pain and/or fullness
  • Rectal bleeding
  • History of rectal foreign body placement
  • Most are in the rectal ampulla and therefore palpable on digital examination

Differential Diagnosis

Anorectal Disorders

Evaluation

Foreign body noted in rectum on lateral abdominal xray
  • Abdominal xray
    • Demonstrate position, shape, 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 small amounts of free air

Management

ED removal

Suitable for non-sharp objects that are in the distal rectum

  • Consider IV sedation and analgesia for larger foreign bodies
  • Perianal block may be useful to help relax anal sphincter
  • 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 can 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.

OR Removal

  • Consult surgery for OR removal if:
    • Size, shape, or location of object has potential to injure anal sphincter during removal
    • Attempts at removal in ED fail
    • Risk of ischemia, perforation, or if excess manipulation required (risk of bacteremia)

Other Considerations

  • Consider GI consult for sigmoidoscopy after removal[1] if:
    • Prolonged retention, objects with sharp corners, 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.