Rectal foreign body

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

• Anal tags
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Cryptitis
• Anal fissure
• Anal fistula
• Anorectal abscess
• Proctitis
• Rectal prolapse
• Rectal foreign body
• Pruritus ani
• Pilonidal cyst
• Constipation
• Condyloma acuminata
• Anal cancer
• Colorectal tumor
• Pedunculated polyp
• Crohn Disease
• Syphilitic fissure
• GC/Chlamydia

Evaluation

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:
  • 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

• Anorectal disorders
• Foreign bodies

References

Authors

Jordan Swartz, Devin Smith, Ross Donaldson, Matthew, Michael Holtz, Nicole Zadzilka, Daniel Eggeman, Neil Young