Rectal foreign body: Difference between revisions
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==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 | ||
==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 | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==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, | **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'' | ||
*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<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== | ||
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==See Also== | ==See Also== | ||
*[[Anorectal | *[[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
- Anal fissure
- Anal fistula
- Anal malignancy
- Anal tags
- Anorectal abscess
- Colorectal malignancy
- Condyloma acuminata
- Constipation
- Crohn's disease
- Cryptitis
- GC/Chlamydia
- Hemorrhoids
- Pedunculated polyp
- Pilonidal cyst
- Proctitis
- Pruritus ani
- Rectal foreign body
- Rectal prolapse
- Syphilitic fissure
Evaluation
- 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
- ↑ Coskun, A. et al. Management of Rectal Foreign Bodies. World J Emerg Surg. 2013; 8:11.