Rectal Foreign Bodies Treatment & Management

  • Author: David W Munter, MD, MBA; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Oct 20, 2011
 

Approach Considerations

Many rectal foreign bodies can be removed in the emergency department (ED). Objects that are sharp or may break should be removed in the operating room (OR). Adequate analgesia and direct visualization are critical to success. Patient relaxation is key.

Arrange for evaluation and treatment of patients who are not candidates for ED removal and patients with suspected rectal lacerations or perforations. Patients with subsequent uncomplicated OR removal are typically discharged after recovery.

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Initial Emergency Management

Transport the patient in a comfortable position. Fluid resuscitation is indicated in cases of hypotension caused by sepsis or hemorrhage.

Perform a rectal examination if no dangerous or sharp foreign body is visible on radiographs. The presence of frank blood is an indication of laceration or perforation and mandates referral of the patient to a surgeon for evaluation.

If the foreign body is palpated on rectal examination, 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, unbreakable, and nonfriable, thus excluding thin glass objects such as light bulbs. Foreign bodies located in the sigmoid colon as opposed to the rectum are much more likely to require operative intervention.[11]

Occasionally, a high-lying rectal foreign body may be palpable on abdominal examination. If the patient is cooperative, a manual transabdominal attempt to manipulate the foreign body into a low-lying position can be made. If this attempt is successful, ED extraction can then be attempted.

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Extraction of Foreign Body

Patients with rectal foreign bodies often develop rectal edema or spasm. Successful removal usually requires direct visualization, which is greatly facilitated by provision of adequate sedation (eg, with a mild sedative such as midazolam) and analgesia (eg, with morphine, hydromorphone, or fentanyl). Position the patient in a knee-chest position; alternatively, place the patient on a gynecology bed with stirrups.

Obtain direct visualization of the foreign body with an anoscope or proctoscope. Use direct lighting. Insert the lubricated scope. Grasp the visualized foreign body with forceps or snares (retractors may also be used), and slowly withdraw it. Minimize the cross-sectional size of the foreign body (turn it if necessary so that it is withdrawn the long-ways).

If the foreign body cannot be visualized, do not make blind attempts removal device; instead, apply gentle pressure on the lower abdomen in an attempt to move the foreign body into the field of vision. If the foreign body cannot be visualized even with abdominal pressure, consult a surgeon or a gastroenterologist.

Difficulties may be encountered in extracting larger objects around which the rectal mucosa has formed a seal. If the foreign body can be visualized and grasped but opposing suction forces hinder removal, insert a lubricated Foley catheter past the foreign body. This breaks the suction seal, creates an air channel, and facilitates removal.

As a rule, extraction attempts should be limited to 20-30 minutes. If the foreign body cannot be removed within this time frame, consult a surgeon or a gastroenterologist.

After successful removal of the foreign body, carefully reexamine the rectum through the anoscope or proctoscope to detect any bleeding or tearing or to identify any additional foreign bodies.

Other extraction techniques that have been described include balloon extraction, in which a pneumatic dilation balloon is inserted distal to the foreign body, inflated, and then withdrawn, pulling the foreign body out along with the inflated balloon.[12]

Discharge patients on oral analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotic medications, as indicated. Antibiotics generally are not indicated in patients discharged home from the ED.

Refer most patients who have undergone ED extraction to a general surgeon for follow-up in 24-48 hours. Some patients with simple extractions can be reevaluated in the ED in 24-48 hours.

It is particularly important to ensure privacy and confidentiality for these patients. Out of embarrassment, patients with rectal foreign bodies may use false names or identification at admission or may elope from the ED after extraction. In some cases, patients do not want any bills to be generated and offer to pay in cash to prevent the creation of an insurance paper trail. Attempt to fulfill such requests.

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Consultations

Consult a general or colorectal surgeon in the following situations:

  • Laceration, perforation, or infection is evident
  • The foreign body is a high-lying object that cannot be moved to a low-lying position
  • The foreign body is made of glass (with the possible exception of thick, sturdy objects that have not been broken)
  • The foreign body is breakable or friable
  • The foreign body is sharp or rough
  • The foreign body is otherwise dangerous
  • Extraction attempts in the ED have been unsuccessful

The usual treatment of these patients by a surgeon involves attempted visualization and removal by means of flexible rectosigmoidoscopy with the patient under general anesthesia. In rare cases, a laparotomy is needed. In some institutions, gastroenterologists manage rectal foreign bodies, except in cases of laceration or perforation and cases where operative intervention is necessary.

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Contributor Information and Disclosures
Author

David W Munter, MD, MBA  Associate Clinical Professor of Emergency Medicine, Eastern Virginia Medical School; Associate Professor of Emergency Medicine, Edward Via Virginia College of Osteopathic Medicine; Medical Director, Emergency Medical Department, Sentara Obici Hospital; Partner, Emergency Physicians of Tidewater, PLC; President of the DESA Consulting Group

David W Munter, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, American College of Physician Executives, Medical Society of Virginia, and Norfolk Academy of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Eugene Hardin, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Edmond A Hooker II, MD, DrPH, FAAEM Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Rosser C. Colonic foreign bodies. JAMA. 1929;39:368-369.

  2. Wagner J. Foreign bodies in the rectum. Am J Surg. 1937;36:266-269.

  3. Caliskan C, Makay O, Firat O, Can Karaca A, Akgun E, Korkut MA. Foreign bodies in the rectum: an analysis of 30 patients. Surg Today. Jun 2011;41(6):795-800. [Medline].

  4. Kurer MA, Davey C, Khan S, Chintapatla S. Colorectal foreign bodies: a systematic review. Colorectal Dis. Sep 2010;12(9):851-61. [Medline].

  5. Smith MT, Wong RK. Foreign bodies. Gastrointest Endosc Clin N Am. Apr 2007;17(2):361-82, vii. [Medline].

  6. Goldberg JE, Steele SR. Rectal foreign bodies. Surg Clin North Am. Feb 2010;90(1):173-84, Table of Contents. [Medline].

  7. Rodriguez-Hermosa JI, Codina-Cazador A, Ruiz B, Sirvent JM, Roig J, Farres R. Management of foreign bodies in the rectum. Colorectal Dis. Jul 2007;9(6):543-8. [Medline].

  8. Clarke DL, Buccimazza I, Anderson FA, Thomson SR. Colorectal foreign bodies. Colorectal Dis. Jan 2005;7(1):98-103. [Medline].

  9. Stack LB, Munter DW. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am. Aug 1996;14(3):493-521. [Medline].

  10. Anderson KL, Dean AJ. Foreign bodies in the gastrointestinal tract and anorectal emergencies. Emerg Med Clin North Am. May 2011;29(2):369-400, ix. [Medline].

  11. Lake JP, Essani R, Petrone P, et al. Management of retained colorectal foreign bodies: predictors of operative intervention. Dis Colon Rectum. Oct 2004;47(10):1694-8. [Medline].

  12. Koornstra JJ, Weersma RK. Management of rectal foreign bodies: description of a new technique and clinical practice guidelines. World J Gastroenterol. Jul 21 2008;14(27):4403-6. [Medline]. [Full Text].

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Typical appearance of a vibrator in the rectum.
Vibrator in the rectum. The patient attempted self-removal with a pair of salad tongs, which also became lodged, resulting in two rectal foreign bodies. Multiple attempts at self-removal are typical in patients with rectal foreign bodies.
 
 
 
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