RECTAL FOREIGN BODIES

Patients with rectal foreign bodies frequently present to the ED because of pain or inability to remove the object. These patients typically present to the ED in a delayed fashion due to embarrassment or multiple attempts at self-removal.

Rectal foreign bodies are inserted (most common) or swallowed. Rectal foreign bodies can be classified as high-lying or low-lying depending upon their location, relative to the rectosigmoid junction. Objects that are past the sacral curve and rectosigmoid junction are difficult to visualize and remove, and often unreachable by rigid proctosigmoidoscope.

Low-lying rectal foreign bodies are normally palpable by digital exam and are candidates for ED removal. Frequent delay in presentation leads to mucosal edema and muscular spasms, further hindering removal. Rectal lacerations and perforations are less common.

Mortality is rare and results from bleeding, rectal perforations or lacerations, or infectious complications.

Morbidity is somewhat more common and primarily a result of lacerations or perforations.

There is a 28:1 male to female distribution. Age distribution is bimodal, with peaks in the 20’s (anal erotism) and 60’s (felt to be secondary to the use of foreign objects for prostatic massage). The typical patient has been described as 20-30 years old.

The chief complaint of patients with rectal foreign bodies usually falls into one of three categories:

In the case of ingested foreign bodies that become lodged in the rectum, the usual etiologic objects are sunflower seeds, toothpicks or bones and the ingestion is typically unknown. These normally present with diffuse abdominal pain, although signs of peritonitis or bowel obstruction may also exist.

Patients may also present with complaints of rectal pain, pruritus or bleeding. A high suspicion index of rectal foreign body must be maintained in psychiatric patients or prisoners who present with rectal pain or bleeding.

The vast majority of patients with rectal foreign bodies will present due to an inability to remove the object. Some patients may claim to have sat or fallen on the object. Older patients may state they were engaged in therapeutic prostatic massage or breaking up faecal impactions when the object was lost. Occasionally, objects such as thermometers or enema tips may become lost. Most patients, however, will admit to the history of insertion by self or a partner

Typically there has been multiple attempts at self-removal, which failed. It is important to ascertain whether the patient attempted any instrumentation in these attempts, as this increases risk of perforation or laceration. The length of time since insertion, as well as presence of rectal or abdominal pain, fever, or rectal bleeding are important elements of the history. Type of object should be determined, as fragile or sharp foreign bodies deserve special consideration.

A special circumstance is assault. Patients should be asked if foreign body is the result of assault, as more serious injuries are seen in these patients. Legal authorities should be notified.

Vital signs and general appearance will indicate if resuscitation is required, fever or hypotension may be indicative of infection or bleeding. An abdominal exam should be performed. Absent bowel sounds, rigidity or peritoneal signs indicate probable perforation. The foreign body, especially if large or in a high-lying position, can occasionally be palpated.

A rectal examination is indicated in the patients who present with abdominal complaints. In general, it should be deferred in patients with known or suspected rectal foreign bodies, especially in prisoners or psychiatric patients, until after the location and type of foreign body is ascertained radiographically. In some cases, dangerous objects such as guns or sharp objects, such as needles or razors, are inserted rectally in an attempt to hide the object, or in the case of psychiatric patients, to injure the examiner. The main purpose of the rectal exam is to check for presence of blood and position of the foreign body.

A hematocrit may be useful in the presence of bleeding. A white blood cell count with differential should be obtained in cases where infection is suspected. For patients who are operative candidates due to the presence of peritoneal signs, signs of sepsis or perforation, or for rectal foreign bodies that cannot be removed in the ED, routine preoperative lab studies should be obtained.

Imaging Studies :

Flat plate of the abdomen or pelvis is indicated. The foreign object can be identified and localized in most cases. A lateral pelvic film sometimes gives additional information on orientation of the foreign body, especially if position of the foreign body (high-lying vs. low-lying) is uncertain. An upright chest radiograph is indicated to evaluate for free air under the diaphragms if perforation is indicated.

Emergency Department Care :

After the radiographs have been reviewed and no dangerous or sharp foreign body is present, a rectal exam should be performed. The presence of frank blood is an indication of laceration or perforation, and patient should be referred to surgery for evaluation. If the foreign body is palpated on rectal exam, the object is considered to be low-lying and a candidate for ED removal. Objects that can be removed in the ED should be smooth, non-breakable and non-friable.

The key elements of successful ED removal are visualization and sedation. Patient will often have developed rectal edema or spasm, so adequate sedation and analgesia are required. Under direct visualization with an anoscope or proctoscope and adequate lighting, the object is grasped with forceps or snares. Retractors have also been used. Difficulties may be encountered in extracting larger objects around which the rectal mucosa has formed a seal. In these cases, placing a Foley catheter beyond the foreign object will break the suction seal and facilitate removal. In general, extraction attempts in the ED should be limited to about 30 minutes.

After removal, a repeat exam, preferably direct, using the anoscope or proctoscope is indicated to evaluate for rectal injuries. In high-lying rectal foreign bodies, if foreign object is palpable on abdominal exam and patient is cooperative, a manual trans-abdominal attempt to manipulate the foreign body into a low-lying position can be made. If successful, ED extraction can then be attempted.

Complications :

The most common complications are rectal laceration and rectal perforation, which are determined by direct visualization. Questionable cases should be referred to general surgery. Other complications include infection with abscesses and sepsis.