Rectal Foreign Bodies: Not always a Simple ED Diagnosis

Authors: Thomas Barrineau, MD PGY-3, Drew Davee, MD PGY-3, Cam Mosley, MD (Attending Physician) (Louisiana State University Health Sciences Center-New Orleans School of Medicine, Emergency Medicine Residency Program, Baton Rouge Campus, Baton Rouge, Louisiana) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Case

A 37-year-old male with no past medical history is brought into the ED complaining of rectal pain. He endorses small amount of blood per rectum and approximately 3 days of nonspecific dull, cramping abdominal pain that has worsened and been associated with the development of some abdominal distention over the past 24 hours. He is reluctant to disclose his full history, only offering that his pain started during intercourse earlier in the week.

Initial Vital Signs: T 38.8C, HR 115, BP 105/65, Sat 98% on RA, RR 18.

Exam reveals an uncomfortable appearing patient. He is tachycardic and tachypneic with clear lungs. His abdomen is distended with guarding in all four quadrants. On deep palpation you feel a mass in the left lower quadrant.

Background

Abdominal pain is a common complaint in the ED, with a vast differential diagnosis. It accounts for approximately 5-10% of all ED visits (13,14,17,20), and is listed as a diagnosis for 35-41% of admitted patients (8).  It remains a diagnostic and management challenge for emergency physicians. While there is a dearth of literature describing the actual incidence, a subset of patients with the complaint of abdominal pain will eventually be diagnosed with a retained rectal foreign body.

There are innumerable anecdotes and radiographs with retained rectal foreign bodies; they are a frequently discussed but uncommonly seen diagnosis that can sometimes prove difficult in management. Written reports of retained rectal foreign bodies date back to surgical literature from the 16^th century (12). Modern reports describe a cornucopia of objects resulting in retained rectal foreign bodies including vegetables, bottles, light bulbs, sex toys, a propane tank, and a billie club. Today, retained rectal foreign bodies remain a persistent chief complaint, with some evidence of an increasing incidence (11,16). While there have been reports in every demographic, the majority of patients are men in their 30s-40s (5,18,21).

In the literature, there is not an official classification system. However, described rectal foreign bodies have been commonly been broken down into categories:

Ingested vs Inserted

Voluntary vs Involuntary

Sexual vs Non-sexual

These categories are not meant to be distinct. Ingested rectal foreign bodies, for example, are objects that can become immobile or impacted once reaching the colon, including small objects like batteries, erasers, and toothpicks. Inserted foreign bodies are most often associated with sexual activity and are often phallic in shape. Nonsexual inserted rectal foreign bodies have been described to include drug mules (“body-packing”), as well as object insertions by mentally ill patients and children. There are case reports of thermometer tips as well as other medical devices becoming lodged in the colon as well (4).

Presentation

History

In the ED, patients often will offer vague complaints with emphasis on abdominal or anorectal pain, rectal bleeding, and/or discharge.  However, patients will often avoid volunteering information about the presence of a foreign body. In one study, 90% of patients presenting with rectal foreign bodies gave inaccurate histories (3). Often, patients have delayed presentation to seek help; there are several documented instances of patients delaying medical care for several years (19). It is important to remain professional and nonjudgmental when trying to elicit history from patients with suspected retained rectal foreign bodies, keeping in mind that they may have been inserted “under duress, as a means of assault, or as a manifestation of a psychiatric disorder” (6).

Physical Exam

Physical exam findings are often vague and can be normal. It is possible to feel a mass on deep abdominal palpation if the foreign body is large enough. If perforation is present, physical exam may reveal an acute abdomen with peritoneal signs.On examination of the external anus, there may appear to be a fissure or other tearing of the anal sphincter. Many patients will attempt to remove the foreign bodies themselves, sometimes resulting in secondary trauma to the anogenital region or rectum itself. It is important to establish the possibility of a rectal foreign body prior to performing DRE, as there are instances of sharp foreign bodies retained in the rectum(9). In this case, it is prudent to obtain imaging prior to any exam. Hematochezia or melenic stool may also be present.

Management

Labs

In general, lab work will be unremarkable and is of limited utility. However, abnormal labs may raise the suspicion for peritonitis and other complications.

Imaging

It is important that an abdominal X-ray is obtained prior to any digital rectal examination to prevent provider injury from sharp objects. Imaging will allow you to assess for free air as well as locate and identify the object. Identifying and locating the object can help predict the likelihood of successful ED extraction.

Predictors of failure include (25):

-hard or sharp objects

-objects longer than 10 cm

-objects located in the sigmoid colon

-objects retained for 2 or more days

An abdominal X-ray with an upright chest X-rayis the usual first step to assess for the object as well as to evaluate for the presence of free air (25). In patients whose history suggests a radiolucent object, a CT scan should be performed. A CT scan should also be performed if the patient has a concerning abdominal exam to definitively rule out perforation or abscess.

Evacuation

Once imaging is obtained confirming an RFB that will not harm the emergency clinician (sharp objects), a digital rectal exam must be performed. If you are unable to palpate the foreign body, a surgeon should be consulted, as it is unlikely that the object will be able to be removed in the ED. Once the object is confirmed to be within the physician’s grasp, there are several techniques that may be employed to increase the chance of successful removal.

Analgesia/sedation – Adequate pain control is essential when removing an RFB, and a perianal block should be performed using 10cc 1% lidocaine with epinephrine mixed with 10cc of 0.25% bupivacaine if the object is not readily extractable (1,2). The perianal block requires that anesthetic be injected first superficially approximately 5mm around the border of the perianal skin. The anesthetic may then be infiltrated into the intersphincteric space around the rectum. In addition to providing anesthesia, it will also relax the external sphincter to facilitate retrieval (1). Procedural sedation using ketamine, fentanyl, midazolam, or etomidate may also be used to make the patient more comfortable as well as to facilitate relaxation of the sphincter muscles.

Positioning – As with all procedures, positioning is a key first step. Placing the patient in the lithotomy position will provide optimal access into the rectal vault (6).

Removal – Before attempting removal, set a time limit (10-20 min) for how long you will attempt removal, and let the patient know that if unsuccessful, you will have to consult a specialist. The next step should be to place sufficient lubrication to allow extraction. The initial attempt should be made with digital manipulation and suprapubic pressure. If this attempt is unsuccessful, an anoscope or small speculum should then be inserted to provide direct visualization of the object. With the object clearly visualized, ring forceps or Kocher clamps may then be used to carefully extract the object. It may also be necessary to place a small Foley alongside object. The Foley will assist in breaking the vacuum seal, and gentle traction may be applied once the balloon has been inflated above the object to assist in removal (7,10). If you have tried multiple techniques and remain unable to remove the object, do not hesitate to discuss with gastroenterology or surgery, as the patient will likely need to go for endoscopy.

Post evacuation – Once the object has been removed, sphincter function must be assessed, and if any abnormalities noted, the patient should be referred to a surgeon for reevaluation. The patient should also be observed for several hours post extraction with frequent repeat abdominal exams to ensure that peritonitis from a perforation is not developing. If the patient develops any concerning signs or symptoms, do not hesitate to obtain additional imaging and consult the surgeon (6).

Surgery

Emergent surgery is required for any patient with peritonitis. Don’t hesitate to call the surgeon if the patient is sick with peritoneal signs on exam. Also, do not forget to resuscitate and administer antibiotics.

Complications

Given that there is such a wide degree of culprit objects, there are variable degrees of complications when dealing with rectal foreign bodies. While most uncomplicated retained rectal foreign bodies are resolved without serious complications, there can be some long term or permanent sequelae. The most common complications are local tissue trauma and tearing of the rectal mucosa, both of which can lead to bleeding. However, traumatic disruption of the anal sphincter can lead to fecal incontinence (18).

Serious complications such as perforation of the rectum and peritonitis are the most feared. Waraich et al describe a case report of a sex toy that led to eventual fecal peritonitis after perforation or the upper rectum, which eventually led to ARDS and was fatal for the patient (22).

Case Resolution

After thorough examination of the patient and consideration of his vital signs, you decide to perform a CT scan of the patient’s abdomen with reveals a pneumoperitoneum, a small amount of free fluid in the paracolic gutter, as well as a sex toy retained in the rectum. Lab work reveals a leukocytosis with left shift. IV fluids, broad spectrum antibiotics, and analgesia is initiated, improving the patient’s vital signs and exam. Surgery is consulted, and they admit and take the patient for laparotomy, FB removal, and washout. He recovers well and is discharged home after a short hospitalization.

Key Points

• Patients may not initially volunteer information.
• Maintain nonjudgmental attitude and professionalism.
• Labs/Imaging may potentially not provide any insight to problem; history is key!
• Predictors of failure include sharp or hard objects, longer than 10cm, located in the sigmoid colon, and those objects that have been retained for more than 2 days.
• Set a time limit and use a stepwise approach in management:
  1. Imaging
  2. Lubrication/DRE
  3. Perianal block/DRE
  4. Speculum/Grasping tools/Foley catheter placement
  5. Avoid pushing the object deeper
  6. Do not blindly grab with instrument, can lead to perforation
  7. Do not attempt to remove sharp objects or objects that may be sharp if they break
  8. General Surgery consult

• If the object is unreachable or sharp consult surgery.
• If the patient has peritoneal signs consult surgery immediately, administer antibiotics, and resuscitate.

References/Further Reading

1. Aphinives P. Perianal block for ambulatory hemorrhoidectomy, an easy technique for general surgeon. J Med Assoc Thai. 2009: 92 (2): 195-197.
2. Bharathi RS, Sharma V, Dabas AK, Chakladar A. Evidence based switch to perianal block for ano-rectal surgeries. International Journal of Surgery. 2010: 8(1): 29-31.
3. Cawich SO, Thomas DA, Mohammed F, Bobb NJ, Williams D, Naraynsingh V. A Management Algorithm for Retained Rectal Foreign Bodies. American Journal of Men’s Health. 2017;11(3):684-692. doi:10.1177/1557988316680929
4. Chiu WK, Hsiao CW, Kang JC, et al. Intrapelvic migration with long-term retention of a rectal thermometer: a case report. Clin Pediatr (Phila) 2007; 46:636.
5. Clarke DL, Buccimazza I, Anderson FA, Thomson SR. Colorectal foreign bodies. Colorectal Dis 2005; 7:98.
6. Cologne KG, Ault GT. Rectal Foreign Bodies: What is the Current Standard? Clin Colon Rectal Surg. 2012 Dec: 25(4): 214-218.
7. Cologne KG, Ault GT. Rectal Foreign Bodies: What Is the Current Standard? Clinics in Colon and Rectal Surgery. 2012;25(4):214-218. doi:10.1055/s-0032-1329392.
8. Cooper GS, Shlaes DM, Salata RA. Intraabdominal infection: differences in presentation and outcome between younger patients and the elderly. Clin Infect Dis 1994; 19:146.
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10. Foreign Body, Rectal. 2016 Aug: (71). Retrieved from https://aneskey.com/foreign-body-rectal/
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