Basics
Description
- 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 trauma
- Knife wounds
- Impalement injuries
- Blunt trauma:
- Motor vehicle accidents
- Waterskiing and watercraft accidents:
- Hydrostatic pressure injury
- Pelvic fractures:
- Bony fragments penetrate rectum
- Foreign body:
- Autoeroticism
- Anal intercourse
- Assault
- Ingestion of sharp objects
- Iatrogenic trauma: Most common cause of rectal injury:
- Barium enema:
- Perforation occurs in 0.04% patients
- 50% mortality
- Colonoscopy:
- 0.2% perforation rate
- Increased risk with polypectomy
- Hemorrhoidectomy
- Urologic 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:
- Guarding
- Rebound tenderness
- Fever
- 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 stool
- Note position of prostate
- Assess perineal integrity:
- Speculum and bimanual exam in all female patients
- Thorough 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 loss
- Leukocytosis/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 pelvis
- IV, 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 object
- Sedation:
- Avoid sedation if possible; ideally, patient can aid extraction by bearing down during procedure
- 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
- Foley catheter:
- Pass above foreign body, inflate balloon, and apply gentle traction to release suction and permit extraction
- Using 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:
- 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
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 IV
- Peds: 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 object
- Laparotomy 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 pain
- Vomiting
- Fever
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)