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RECTAL FOREIGN BODIES Rectal Examination Powered By Docstoc

                             RECTAL FOREIGN BODIES
      Jan Muhammad Memon, Nazar Ali Memon, Roshan Ali Solangi, Mohan Khataomal Khatri
             Department of Surgery, Nawabshah Medical College, Nawabshah, Pakistan

INTRODUCTION                                             EVALUATION
       Anorectal simulation and penetration is a rela-        Individuals present with a host of complaints
tively common sexual practice. Digital and penile        like anorectal pain and rectal bleeding
penetrations are the most common forms. A seg-           (proctorrhagia) (66.6%) and unsurprisingly a his-
ment of the homosexual population practices fist         tory of anal introduction is given only in 33.3%
fornication, a technique that involves insertion of      cases and difficulty in passing stools (dyschezia).9
fist and arm into the anorectum. This activity can
                                                         •    Embarrassed, apprenhensive and uncomfort-
result in severe injury to the anal sphincter and
                                                              able patient may deny ill doing or give out
perforation of the rectum and colon.1 Anorectal
                                                              landish explanations claiming to have fallen
foreign body is no longer a medical oddity, rather
                                                              on the foreign body which miraculously dis-
it is encountered frequently.2,3,4 The vast majority
of objects are inserted by; self introduction in chil-
dren or psychiatric patients, in victim of assault       •    The history should include the nature of de-
and as a result of sexual gratification. Iatrogenic           vice inserted into the rectum and the interval
foreign bodies include thermometers, enema tips               between insertion and presentation at hos-
and catheters. The objects placed as a result of              pital and how many times attempts have been
assault, trauma or eroticism consist of a diverse             made to retrieve the object.
collection including sex toys (dildos), tools and
instruments, bottles, cans, jars, pipes and tubing,      •    A history of previous sexually transmitted dis-
fruits and vegetables, stones, light bulbs and flash          ease may suggest the possibility of infection
lights.5                                                      with human immunodeficiency virus, syphilis
                                                              and hepatitis B or C.
       The level of entrapment will help to stratify
the likelihood of transanal extraction. Those in low     •    Presence of fever, abdominal tenderness and
or mid rectum up to a level of 10 cm can be most              signs of peritonitis suggest the possibility of
often removed transanally while those above 10                perforation.
cm may require laparotomy for retrieval.6 General        •    Rectal examination will identify the presence
and colorectal surgeons are likely to encoun-                 of a foreign body in the distal rectum. A for-
ter patients with retained foreign bodies par-                eign body above the recto sigmoid junction
ticularly if they practice in communities with a              may not be palpable. Rectal examination and
high prevalence of penetrating anorectal sti-                 anoscopic evaluation can reveal an injury to
mulation.                                                     the anal canal or sphincter mechanism.
      Numerous instruments have been used to             •    Laboratory investigations are performed to
assist extraction, including obstetric forceps, ten-          determine the possibility of rectal perfora-
aculum, ring forceps and a vacuum extractor. A                tion. An elevated white cell count may indi-
Foleys catheter with balloon can also assist re-              cate it.
moval. Even a Sengstaken-Blackmore tube has
been used. Use of a large bore operative procto-         •    An abdominal radiograph will demonstrate
scope may also help in retrieval.7,8                          the size, shape, location, number and direc-
                                                              tion of foreign bodies. Small air bubbles
      Anal dilation may be necessary and in rare              along the psoas muscle suggest retroperito-
instances sphinctrotomy may be required. Addi-                neal rectal perforation. This sign is very subtle
tionally, all the patients should be referred for psy-        and may not be present. An upright chest x-
chological evaluation to avoid similar problem in             ray should be carefully examined for the pres-
future and to minimize psychological trauma in                ence of free air under the diaphragm associ-
assault cases.                                                ated with an intraperitoneal rectal perfora-
      This review summarizes our exposure                     tion.
and medical literature to clarify the treatment          •    A surgeon who is called to see a patient with
strategy.                                                     a retained foreign body must answer two

Gomal Journal of Medical Sciences January–June 2008, Vol. 6, No. 1                                           1
     questions. Does the patient have rectal per-       anal sphincter and smallest member of the team a
     foration? Can the foreign body be removed          female surgeon may be used to retrieve the for-
     transanally in the emergency department            eign body transanally. Female surgeons may have
     without a formal regional or general anes-         attributes that are advantageous to a surgical car-
     thesia?                                            rier such as being sympathetic, calm and orga-
                                                        SURGICAL INTERVENTION
      The majority of objects are easily removed
in emergency department. Correct position is im-               Intraperitoneal colonic or rectal perforation
portant. Relaxation is essential and intravenous        is easy to detect with free air under the diaphragm
sedation is often necessary to retrieve the foreign     and obvious peritoneal signs on physical exami-
body. Local anesthesia like perianal block with         nation while retroperitoneal perforation is difficult
0.5% lidocaine injected into the anal sphincters        to diagnose. There is usually a delay of few days
can assist with relaxation maneuvers and analge-        before the pelvic and perineal sepsis becomes evi-
sia. Perianal subcutaneous infiltration of 10 ml is     dent. Appropriate treatment can then be carried
followed by a four quadrant sub-mucosal infiltra-       out.9,11 Extremely rarely laparotomy is necessary
tion of anal canal. Conscious patient may be able       to remove an object as a primary method of treat-
to assist with valsalva maneuvers. Foreign body         ment with a high lying foreign body in the rec-
should be visualized with an anoscope or procto-        tum.1 This may allow trans-abdominal manipula-
scope, grasped with tenaculum and gently ex-            tion and transanal extraction.2,7,8,9,11,12,13 It is manda-
tracted. If the object is not palpable on rectal ex-    tory if signs of rectal perforation and peritonitis
amination, aggressive attempts at extraction in the     are present. Repair of rectal perforation with proxi-
emergency room should not be made. Most pa-             mal colostomy is indicated. Sigmoidoscopy,
tients with retained foreign bodies can be treated      barium enema and third generation cephalospor-
by trans-anal extraction of the object under the        ins should be given before colostomy is per-
regional or general anesthesia in lithotomy posi-       formed.14
tion Anal dilatation may be necessary in rare in-
stances. Lateral internal sphincterotomy may be         WHAT TO DO:
required and can be safely performed without any
                                                        •     Plain abdominal radiograph for the nature
long-term alteration in continence. A complete anal
                                                              and location of foreign bodies.
sphincterotomy with immediate repair have also
been reported with success when all other mea-          •     Abdominal and rectal examination to rule out
sures fail.1, 2, 9                                            rectal perforation and peritonitis.
Foley’s Catheter Technique: Insufflation of air         •     Sedate the patient with intravenous benzo-
through Foley’s catheter (20-22 Fr) inserted along            diazepines or narcotics and place the pa-
side the object in to the rectum and lower sig-               tient in Sims position.
moid colon can break the negative suction. The
                                                        •     When the object is too high to reach or
balloon of catheter can then be inflated with 30-35
                                                              sphincter tightness is present then remove it
cc of normal saline and gently pulled back to bring
                                                              under regional or general anesthesia.
the object down to the rectum to be retrieved. It is
a good way to break the negative suction pres-          •     Immediate attempt at colonoscopic extrac-
sure.6                                                        tion of foreign body is associated with bleed-
                                                              ing or obstruction.
Manual Extraction: When foreign body migrates
to sigmoid colon, an ideal instrument would be          •     Observation for 24 hours after removal.
able to grasp a large object with out damaging
                                                        •     Rectal perforation requires a diverting stoma.
the bowel wall. No such instrument exists. The
surgeon’s hand is the best surgical instrument.         •     Sphincter integrity must be assessed for con-
Eflaiha13 reported that after comparing the diam-             tinence.
eter of female and male hands in 20 surgeons, the
mean diameter in the females was 5.5 cm and males       WHAT NOT TO DO:
7 cm and also compared the diameter of transanal
                                                        •     Do not pressurize the patient to give an ac-
endoscopic microscopy (TEM) device, the female
                                                              curate history because he may be embar-
hand was 1.7 cm greater as compared to 3.2 cm
                                                              rassed and intimidation will not help.
for male hands and concluded that a female hand
is a useful instrument for retrieving colorectal for-   •     Never attempt to extract until patient’s anal
eign bodies. The hands of a lady may have the                 sphincter is fully relaxed by local, spinal or
advantage without damaging the integrity of the               general anesthesia.

Gomal Journal of Medical Sciences January-June 2008, Vol. 6, No. 1                                               2
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     tearing or perforation.                                   eign Bodies. J Chin Med Assoc 2003; 66:
•    Do not discharge the patient having contin-               606-11.
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                                                               Surg Clin North Am 1994; 74; 1491-1505.
                                                         11.   Nicholis RJ, Dozois RR. Surgery of the Colon
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     Schecter WP Albo RJ. Removal of rectal foreign            and Rectum.
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                                                               and foreign bodies of rectum. Ann Surg 1976;
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                                                               Dr. Jan Muhammad Memon
6.   Kingsley A, Abcarian H. Colorectal foreign bod-           Assistant Professor Surgery
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     1985; 28: 94-104.                                         Nawabshah
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Gomal Journal of Medical Sciences January–June 2008, Vol. 6, No. 1                                          3

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