Basics
Description
- Self-insertion (autoeroticism):
- Phallic substitutes inserted by patient or partner
- Usually men aged 20-40 yr, with male to female ratio 20:1
- Ingested objects lodged in rectum:
- Chicken bones
- Fish bones
- Toothpick
- Iatrogenic accidental:
- Thermometer
- Enema tips
- Foreign bodies (FBs) used to aid in removal of feces
- Assault:
- Knife or pipe forcibly inserted
- Incidence of perforation is very high.
- Concealment:
- Body packing, "mules" illegally transporting drugs
Diagnosis
Signs and Symptoms
- Complaint of rectal FB
- Rectal fullness
- Rectal pain
- Perirectal abscess (with imbedded bones/toothpick)
- FB on rectal exam:
- High-lying FBs are located proximal to rectosigmoid junction and are not palpable on rectal exam.
- Low-lying FBs are usually located in rectal ampulla and are palpable on rectal exam.
- Some patients may not be forthcoming with history
- Can present with vague symptoms of abdominal pain or obstruction
- Can present as bowel perforation with full peritonitis
- Often late presentation hours or days after placement, following repeated failed attempts at removal
- Rectal Organ Injury Scale (proposed by American Association for the Surgery of Trauma):
- Grade I-Hematoma: Contusion or hematoma without devascularization:
- Most injuries due to rectal FB are Grade I
- Grade II-Laceration 50% circumference
- Grade III-Laceration >50% circumference
- Grade IV-Full-thickness laceration with extension into perineum
- Grade V-Devascularized segment
Essential Workup
- Identify number, type, and duration of FBs and mechanism of insertion.
- Physical exam with emphasis on abdominal and rectal exam
- Classified as high-riding vs. low-riding based on relationship to rectosigmoid junction
- Biplane radiographic films to confirm number and size of FBs
- Serious injury more common with assault
Diagnosis Tests & Interpretation
Lab
- CBC:
- For bleeding or peritonitis
- Urinalysis:
- For urethral/bladder injuries
Imaging
- Plain radiograph:
- Consider doing kidneys, ureters, and bladder (KUB) radiograph prior to rectal exam to rule out objects harmful to examiner.
- Define and locate FB.
- Assess for complications of retained FB including bowel perforation and obstruction.
- May be used serially to follow descent of FB
- CT scan of abdomen/pelvis:
- To exclude perforation or abscess formation
Differential Diagnosis
- Pseudo-FB:
- Patients insist there is FB when radiograph, rectal exams, and proctoscopy results are normal.
- Perirectal abscess
- Hemorrhoid
Treatment
Pre-Hospital
Cautions:
- Patient has usually tried to remove FB and failed.
- Further attempts at extraction will not work and could cause perforation.
Initial Stabilization/Therapy
- Perforation with peritonitis and sepsis:
- 0.9% NS IV fluid 500 mL bolus
- Broad-spectrum antibiotics (anaerobic and gram-negative aerobes):
- Cefoxitin, cefotetan, ticarcillin-clavulanate, ampicillin-sulbactam, imipenem, meropenem, ertapenem, or
- Metronidazole/clindamycin _+ aminoglycoside/3rd-generation cephalosporin/fluoroquinolone/aztreonam
- Urgent surgical consult
- Advanced trauma life support (ATLS) with evidence of other trauma
Ed Treatment/Procedures
- Appropriate sedation and analgesia is important to overcome spasm, rectal edema.
- Avoid enemas or suppositories.
- Low-lying small rectal FBs that are not fragile or sharp are candidates for ED removal:
- Firmly hold bimanually or with forceps
- Remove with gentle but firm continuous traction to overcome anal sphincter.
- Colonic mucosa tightly adherent to distal end of FB creates vacuum and impedes withdrawal of object:
- Passage of Foley catheter beyond object with insufflation of air breaks vacuum and permits retrieval.
- Awake and cooperative patients can facilitate transanal extraction with valsalva.
- May use instruments to assist with extraction: Obstetrical forceps, tenaculum, ring forceps, vacuum extractor
- 60% of rectal FBs may be removed transanally in the ED under proper sedation.
- Following extraction, anorectum must be thoroughly evaluated to rule out occult injury.
- High-lying rectal FBs:
- Not immediately accessible through rectum
- Usually require surgical or GI consult
- Attempt may be made to position object into low-lying position with gentle abdominal pressure
- Avoid blind transanal removal
- Direct visualization with lubricated operating anoscope (after blockage of sphincter and pudendal nerve with local anesthesia)
- Admission and observation for spontaneous descent (with serial radiographs)
- Laparotomy may be necessary as last resort if other methods fail, or if patient has evidence of perforation.
- Consider surgical or GI consult for other complicated rectal FBs:
- Larger objects
- Objects that have remained >24 hr with resulting edema
- Objects with sharp edges
- Proctoscopy/sigmoidoscopy after extraction to examine colonic mucosa
- Body packers:
- Ruptured packets of concealed illicit drugs can cause systemic toxicity, bowel necrosis, and death.
- Sharp instruments should not be used for retrieval, and other instruments should be used with extreme caution.
Medication
- Ampicillin-sulbactam (Unasyn): 3g IV q6h (peds: 100-200 mg/kg/d div. q6h)
- Ceftriaxone (Rocephin): 1-2 g IV q12h (peds: 50-75 mg/kg IV daily)
- Ciprofloxacin (Cipro): 400 mg IV q8-12h
- Clindamycin: 600-900 mg (peds: 20-40 mg/kg/24h) IV q8h
- Levofloxacin (Levoquin): 500 mg IV q24h
- Metronidazole: 15 mg/kg IV once, then 7.5 mg/kg IV q6h
- Piperacillin-tazobactam (Zosyn): 3.75 g IV q6h or 4.5 g IV q8h (peds: 240-400 mg/kg/d div. q6-8h)
- Removal under general anesthesia for children who are too young to cooperate
- It is probably child abuse if FB other than enema tips or thermometer is present.
Follow-Up
Disposition
Admission Criteria
- Failed extraction in ED requires surgical removal in the operating room.
- Evidence of mucosal tear on proctoscopy should be observed for 24 hr (no antibiotic indicated).
- Symptom of rectal pain associated with removal of sharp FB indicates possibility of small perforation with developing abscess and requires exam under anesthesia.
Discharge Criteria
- Reliable patient with atraumatic insertion and removal of rectal FB
- Instruct to return for rectal pain, abdominal pain, fever, or massive rectal bleeding.
Issues for Referral
GI or surgery consult if unable to remove FB in ED
Followup Recommendations
Flexible sigmoidoscopy or rigid proctoscopy to evaluate for mucosal injury following retrieval of rectal FB regardless of method used is recommended.
Pearls and Pitfalls
- Passage of Foley catheter beyond object with insufflation of air breaks vacuum and permits retrieval.
- Provide adequate sedation/analgesia when attempting FB removal in the ED.
Additional Reading
- Clarke DL, Buccimazza I, Anderson FA, et al. Colorectal foreign bodies. Colorectal Dis. 2005;7:98-103.
- Coskun A, Erkan N, Yakan S, et al. Management of rectal foreign bodies. World J Emerg Surg. 2013;8:11.
- Hellinger MD. Anal trauma and foreign bodies. Surg Clin North Am. 2002;82:1253-1260.
- Rodriguez-Hermosa JI, Codina-Cazador A, Ruiz B, et al. Management of foreign bodies in the rectum. Colorectal Dis. 2007;9:543-548.
- Smith MT, Wong RK. Foreign bodies. Gastrointest Endosc Clin N Am. 2007;17:361-382.
See Also (Topic, Algorithm, Electronic Media Element)
Rectal Trauma
Codes
ICD9
937 Foreign body in anus and rectum
ICD10
T18.5XXA Foreign body in anus and rectum, initial encounter
SNOMED
- 70176004 foreign body in rectum (disorder)