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Rectal Trauma, Emergency Medicine

Basics

Description

- Foreign body: - Autoeroticism - Anal intercourse - Assault - Ingestion of sharp objects

- Colonoscopy: - 0.2% perforation rate - Increased risk with polypectomy

- Hemorrhoidectomy - Urologic and Ob-Gyn procedures:

- Perineal, anal, or lower abdominal pain - Signs of perforation or peritonitis: - Guarding - Rebound tenderness - Fever

- Inspect and palpate thoroughly buttocks, anus, and perineum. - Identify entrance and exit wounds if penetrating trauma. - Perform digital rectal exam: - Assess for gross blood or guaiac-positive stool - Note position of prostate

- With patient in lithotomy position: - Local anesthesia to maximize anal sphincter dilation - Gentle digital sphincter dilation - Obstetric, ring, or biopsy forceps, tenaculum, or suctioning device to aid extraction - Suprapubic pressure - Patient Valsalva

- Surgical consultation: - Peritonitis - All traumatic rectal mucosal lacerations - Objects >10 cm from anal verge - Sharp objects whose removal may provoke mucosal injury - Inability to extract foreign body in ED

  • Injury to rectal mucosa
  • Simple contusion to full-thickness laceration with extension into peritoneum or perineum
  • 2/3 of rectum is extraperitoneal.

Etiology

  • Penetrating trauma:Gunshot wounds: 80% penetrating rectal traumaKnife woundsImpalement injuries
  • Blunt trauma:Motor vehicle accidentsWaterskiing and watercraft accidents:Hydrostatic pressure injuryPelvic fractures:Bony fragments penetrate rectum
  • Foreign body:AutoeroticismAnal intercourseAssaultIngestion of sharp objects
  • Iatrogenic trauma: Most common cause of rectal injury:Barium enema:Perforation occurs in 0.04% patients50% mortalityColonoscopy:0.2% perforation rateIncreased risk with polypectomyHemorrhoidectomyUrologic and Ob-Gyn procedures:
  • Rectal injury may result from thermometer insertion.
  • Any rectal trauma in young children should raise the suspicion of nonaccidental trauma.

Diagnosis

Signs and Symptoms

  • Perineal, anal, or lower abdominal pain
  • Signs of perforation or peritonitis:GuardingRebound tendernessFever
  • Rectal bleeding
  • Obstipation
  • Presence of pelvic fracture
  • History of anal manipulation, foreign-body insertion, sexual abuse

History

  • Time and mechanism of injury
  • Suspect rectal injury in all patients with gunshot wound, stab wound, or impalement injury to trunk, buttocks, perineum, or upper thigh.
  • Consider in any patient with history of anal manipulation complaining of lower abdominal or pelvic pain.

Physical Exam

  • Inspect and palpate thoroughly buttocks, anus, and perineum.
  • Identify entrance and exit wounds if penetrating trauma.
  • Perform digital rectal exam:Assess for gross blood or guaiac-positive stoolNote position of prostate
  • Assess perineal integrity:Speculum and bimanual exam in all female patientsThorough genitourinary exam in all male patients, including prostate exam

Essential Workup

  • Labs: CBC, urinalysis
  • Acute abdominal series
  • CT abdomen and pelvis if blunt trauma
  • Sigmoidoscopy: Following extraction of foreign body
  • Evidentiary exam: Required in cases of sexual assault

Diagnosis Tests & Interpretation

Lab

  • CBC:Blood lossLeukocytosis/bandemia suggesting peritonitis
  • Type and screen:If evidence of hemorrhage
  • Urinalysis:Evaluate for fecal matter

Imaging

  • Supine/upright abdominal films, pelvic radiographs:Evaluate for pneumoperitoneum or extraperitoneal and extrarectal densities suggesting perforation.Identify location, size, and shape of foreign body.Identify pelvic fracture or diastasis of symphysis pubis, which may accompany rectal injury.
  • CT abdomen and pelvisIV, PO, or PR contrast (gastrografin) per the clinical situation

Diagnostic Procedures/Surgery

  • Retrograde urethrogram if high-riding prostate noted on rectal exam
  • Contrast enema helpful only in situations where perforation is unclear:Water-soluble contrast (e.g., gastrografin)

Differential Diagnosis

  • Colon injuries
  • Genitourinary injuries

Treatment

Pre-Hospital

  • Airway, breathing, and circulation
  • Spinal precautions if blunt trauma
  • Fluid resuscitation if blood loss, hypotension
  • Do not attempt removal of rectal foreign body
  • Control bleeding

Initial Stabilization/Therapy

Penetrating or blunt abdominal trauma, follow trauma protocols:

  • Primary survey
  • Resuscitation
  • Secondary survey
  • Treatment

Ed Treatment/Procedures

  • Tetanus prophylaxis if needed
  • Broad-spectrum antibiotics if significant mucosal disruption or signs of peritonitis are present
  • Foley catheter (after excluding urethral injury)
  • Rectal foreign body removal in ED:Determine location and type of foreign objectSedation:Avoid sedation if possible; ideally, patient can aid extraction by bearing down during procedureWith patient in lithotomy position:Local anesthesia to maximize anal sphincter dilationGentle digital sphincter dilationObstetric, ring, or biopsy forceps, tenaculum, or suctioning device to aid extractionSuprapubic pressurePatient ValsalvaFoley catheter:Pass above foreign body, inflate balloon, and apply gentle traction to release suction and permit extractionUsing 3 catheters, pass each alongside of foreign body, inflate, and gently pull (helpful for smooth objects or if unable to pass Foley above object)Sigmoidoscopy to evaluate mucosal injury following extraction
  • Surgical consultation:PeritonitisAll traumatic rectal mucosal lacerationsObjects >10 cm from anal vergeSharp objects whose removal may provoke mucosal injuryInability to extract foreign body in ED

Medication

  • Antibiotics with coverage against gram-negative and anaerobic organisms:Ampicillin/sulbactam:Adults: 3 g q6h IV (peds: 50 mg/kg IV)Cefotetan:Adults: 2 g q12h IV (peds: 40 mg/kg IV)Cefoxitin:Adults: 2 g q6h IV (peds: 80 mg/kg q6h IV)Piperacillin/tazobactam:Adults: 3.375 g IV (peds: 75 mg/kg IV)Ticarcillin/clavulanate:Adults: 3.1 g IV (peds: 75 mg/kg IV)
  • Additional anaerobic coverage:Clindamycin:Adults: 600 " 900 mg IV (peds: 10 mg/kg IV)Metronidazole:Adults: 1 g IV (peds: 15 mg/kg IV)
  • Combination therapy:Adults: Ampicillin 500 mg IV q6h, gentamicin 1 " 1.7 mg/kg IV, and metronidazole 1 g IVPeds: Ampicillin 50 mg/kg IV q6h, gentamicin 1 " 1.7 mg/kg IV, and metronidazole 15 mg/kg IV
  • Sedation and analgesia:Fentanyl: 2 " 3 Όg/kg IV (peds and adults)Midazolam: 0.01 " 0.2 mg/kg IV (peds and adults)Lidocaine: Topical or injectable

Surgery/Other Procedures

  • Perforation
  • Torn sphincter
  • Foreign body:General anesthesia required to remove high-riding or sharp objectLaparotomy is last resort

Follow-Up

Disposition

Admission Criteria

  • Perforation
  • Significant bleeding
  • Unstable vital signs
  • Abdominal pain
  • Torn anal sphincter
  • Foreign body that requires extraction in operating room

Discharge Criteria

  • Stable vital signs
  • No abdominal pain
  • Normal sigmoidoscopy/anoscopy exam

Follow-Up Recommendations

  • Repeat abdominal exam 12 " 24 hr
  • Return to ED:Abdominal painVomitingFever

Pearls and Pitfalls

  • Consider rectal injury in all patients presenting with abdominal pain following lower GI or genitourinary procedure.
  • 60% of foreign bodies can be removed in ED.
  • Failure to recognize perforation following extraction of foreign body
  • Creativity and imagination can aid successful extraction of foreign body in ED.

Additional Reading

  • Bak Y, Merriam M, Neff M, et al. Novel approach to rectal foreign body extraction. JSLS. 2013;17(2):342 " 345.
  • Cleary RK, Pomerantz RA, Lampman RM. Colon and rectal injuries. Dis Colon Rectum. 2006;49(8):1203 " 1222.
  • Manimaran N, Shorafa M, Eccersley J. Blow as well as pull: An innovative technique for dealing with a rectal foreign body. Colorectal Dis. 2009;11:325 " 326.
  • Tonolini M. Images in medicine: Diagnosis and pre-surgical triage of transanal rectal injury using multidetector CT with water-soluble contrast enema. J Emerg Trauma Shock. 2013;6(3):213 " 215.

See Also (Topic, Algorithm, Electronic Media Element)

  • Abdominal Trauma, Blunt
  • Abdominal Trauma, Imaging
  • Abdominal Trauma, Penetrating
  • Colon Trauma

Codes

ICD9

  • 664.30 Fourth-degree perineal laceration, unspecified as to episode of care or not applicable
  • 863.45 Injury to rectum, without mention of open wound into cavity
  • 863.55 Injury to rectum, with open wound into cavity

ICD10

  • O70.3 Fourth degree perineal laceration during delivery
  • S36.60XA Unspecified injury of rectum, initial encounter
  • S36.63XA Laceration of rectum, initial encounter
  • S36.62XA Contusion of rectum, initial encounter
  • S36.61XA Primary blast injury of rectum, initial encounter
  • S36.69XA Other injury of rectum, initial encounter

SNOMED

  • 125635006 Injury of rectum (disorder)
  • 262879002 Laceration of rectum (disorder)
  • 34262005 Fourth degree perineal laceration involving rectal mucosa (disorder)
  • 262877000 Contusion of rectum (disorder)
  • 29880001 Injury of rectum with open wound into abdominal cavity (disorder)