Before the end…

The End.

Or, Rectal Foreign Bodies

Melissa Ying R2

Dec 15 2006

Objectives Develop a systematic approach to rectal

and sigmoid foreign bodies Identify potential sources of foreign bodies

and their significance Classify rectal foreign bodies in a manner

relevant to their management Review current literature

History of RFB First documented in 16th century Few studies conducted until the 1970s

onwards.

Systematic Approach Presentation Etiology Differential Diagnostic Aids Management Potential Complications

Presentation Confession Pain in rectum/Local discomfort Obstruction Perforation Sepsis or Toxic Shock Toxicity Incidental

Etiology Ingested Inserted (transanally)

Autoerotic Concealment Accidental Assault

Iatrogenic Transmural

Iatrogenic, transmural Intraabdominal

pacemaker in 2 yr old child

Still functioning Caused failure to

thrive.

International Journal of Cardiology Volume 107, Issue 2 , 15 February 2006, Pages 287-288

Differential Diagnosis Tumour Feces Prolapse

Diagnosis depends on… History Abdominal exam Rectal exam Plain radiography

Classifications Benign vs. Malignant? Cystic vs. Solid? Sharp vs. Dull? Inert vs. Chemically active? Gas, liquid, solid? Animal, vegetable, mineral?

Cystic? 100 watt lightbulb Removed intact using

Foley catheters and mineral oil

Annals of Emergency MedicineNovember 1982

Solid? 30 cm wooden rod

inserted transanally and retained for 1 month

Removed transanally using rigid NG tube to introduce air proximally

Journal of the American College of Surgeons Volume 203, Issue 1 , July 2006, Pages 132-133

…or?? Epoxy resin injected

by patient Presented with pain 5

hrs later Poison control

contacted Rectal “cast” delivered

by manipulation

Journal of Gastrointestinal Surgery Volume 9, Issue 5 , May-June 2005, Pages 747-749

Animal? …sorry, no story. Just

pictures.

Potential Complications Sepsis

Embolic stroke

Perforation Toxicity Local injury (burns, tears) Missed assault

Management Resuscitate (if needed) Initial exam

Simple removal?

Plain radiograph Free air, object identification, localization

Exam under Anaesthesia May need to overcome “vaccuum” phenomenon

Management Laparoscopy

Lap assisted removal without enterotomy Enterotomy

Laparotomy Likely enterotomy Repair of any perforation

Management Visualize rectosigmoid with sigmoidoscopy Should be managed by general or

colorectal surgeon

Lap-assisted removal Insertion of

“toothbrush case” for self-enema

Dis Colon Rectum. 2005 Oct;48(10):1975-7

The packer: Most common drugs: cannabis products,

heroin, cocaine “Packs” designed to be radiolucent May present with obstruction or toxicity

The packer:

Eur Radiol (2004) 14:736–742

One study’s population… All 13 patients were male Age range 2–66 years. 7 Caucasian, 4 African and 1 Asian. The foreign bodies included:

a penknife, an aerosol deodorant spray can, a blue plastic tumbler, a plastic bag containing two bank-notes and some marijuana, a plastic packet containing fish hooks, a penlight torch, a broomstick, a battery powered vibrator, a primus stove, a cap of an aerosol can, a piece of wire, a piece of hosepipe wrapped with wire and an iron bar.

Colorectal Disease Volume 7 Issue 1 Page 98 - January 2005

One study’s population:Entered via;

anal autoeroticism (3) concealment (2) attention seeking behaviour (3) accidental (1) assault (2) to alleviate constipation (2).

Colorectal Disease Volume 7 Issue 1 Page 98 - January 2005

One study’s population: Plain radiographs accurately demonstrated the

site of the foreign body in 8 patients. Extraction via

Laparotomy (5) 2 patients with peritonitis 3 who required extraction by colotomy.

Transanal extraction (7): 4 required general anaesthesia to facilitate extraction; 3 under conscious sedation in ER

The remaining patient extracted the foreign body himself and presented to hospital with a rectal perforation.

Colorectal Disease Volume 7 Issue 1 Page 98 - January 2005

Questions?? “I have no idea how

that got there…”