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
 
*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 14: Line 14:
  
 
==Evaluation==
 
==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]]]]
 
[[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 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==
 
==Disposition==
Line 52: Line 60:
  
 
==See Also==
 
==See Also==
*[[Anorectal Disorders]]
+
*[[Anorectal disorders]]
 
*[[Foreign bodies]]
 
*[[Foreign bodies]]
  
 
==References==
 
==References==
 
<references/>
 
<references/>
 +
 
[[Category:GI]]
 
[[Category:GI]]
 +
[[Category:Symptoms]]

Latest revision as of 15:09, 20 October 2019

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

Body spray can in rectum on abdominal plain film.
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

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