Difference between revisions of "Rectal foreign body"
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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 | |
| − | == | + | |
| − | + | ==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 DDX}} | ||
| + | |||
| + | ==Evaluation== | ||
| + | [[File:PMC3601006 1749-7922-8-11-1.png|thumb|Body spray can in rectum on abdominal plain film.]] | ||
| + | [[File:Rectal_fb.JPG|thumb|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== | ==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 for:<ref>Coskun, A. et al. Management of Rectal Foreign Bodies. World J Emerg Surg. 2013; 8:11.</ref> | ||
| + | **Prolonged retention | ||
| + | **Object with sharp corner(s) | ||
| + | **Toxic appearing patient | ||
| + | |||
| + | ===Body Stuffing=== | ||
| + | *Ingestion of illicit drugs while pursued by law enforcement; usually small quantity | ||
| + | *Consider activated charcoal | ||
| + | *Consider whole bowel irrigation if develop toxicity | ||
| + | *Consider discharge if do not develop toxicity after 4hr obs | ||
| + | |||
| + | ==Disposition== | ||
| + | *Consider observation for at least 12hr if concern for rectal perforation | ||
| + | |||
| + | ==See Also== | ||
| + | *[[Anorectal disorders]] | ||
| + | *[[Foreign bodies]] | ||
| + | |||
| + | ==References== | ||
| + | <references/> | ||
| − | |||
| − | |||
| − | |||
[[Category:GI]] | [[Category:GI]] | ||
| + | [[Category:Symptoms]] | ||
Latest revision as of 15:09, 20 October 2019
Contents
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
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 for:[1]
- Prolonged retention
- Object with sharp corner(s)
- Toxic appearing patient
Body Stuffing
- Ingestion of illicit drugs while pursued by law enforcement; usually small quantity
- Consider activated charcoal
- Consider whole bowel irrigation if develop toxicity
- Consider discharge if do not develop toxicity after 4hr obs
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.