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Foreign Bodies, Rectum: Treatment & Medication
Updated: Sep 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Prehospital Care
Transport the patient in a comfortable position. Fluid resuscitation is indicated in cases of hypotension caused by sepsis or hemorrhage.
Emergency Department Care
- 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 the patient should be referred 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, nonbreakable, 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.9
- 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 and analgesia. Under direct visualization with an anoscope or proctoscope and adequate lighting, the object is grasped with forceps or snares. Retractors may also be used. Difficulties may be encountered in extracting larger objects around which the rectal mucosa has formed a seal. In these cases, inserting a Foley catheter beyond the foreign object breaks the suction seal and facilitates removal. Generally, limit extraction attempts in the ED to approximately 30 minutes.
- After removal, a repeat examination, preferably direct, using the anoscope or proctoscope is indicated to evaluate for rectal injuries.
- 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 successful, ED extraction can then be attempted.
Consultations
- Consult a general or colorectal surgeon in the following situations:
- When laceration, perforation, or infection is evident
- High-lying objects that cannot be converted to low-lying
- Glass objects, with the possible exception of thick, sturdy unbroken objects
- Breakable or friable objects
- Sharp or nonsmooth objects
- Dangerous objects
- Those for which extraction attempts in the ED have been unsuccessful
- The usual treatment of these patients by surgery includes attempted visualization and removal under general anesthesia using flexible rectosigmoidoscopy. In rare cases, a laparotomy is needed.
- In some institutions, gastroenterology manages rectal foreign bodies with the exception of cases of laceration or perforation, or those requiring operative intervention.
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Analgesic, Narcotic
These agents facilitate the visualization and successful removal of the object.
Morphine sulfate (Astramorph, Duramorph, MS Contin, MSIR, Oramorph)
DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.
Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC; reassess hemodynamic effects of dose
Pediatric
Infants and children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn; not to exceed 15 mg/dose; may initiate at 0.05 mg/kg/dose
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO inhibitors, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Hydromorphone
Potent semisynthetic opiate agonist similar in structure to morphine. Approximately 7-8 times as potent as morphine on mg-to-mg basis with shorter or similar duration of action.
Adult
1-4 mg PO q4-6h prn; alternatively 1-2 mg IV/IM/SC q4-6h prn; adjust dose according to pain scale assessment
Pediatric
Not established
Hydantoins may decrease effects; phenothiazines, CNS depressants, and tricyclic antidepressants may increase toxicity
Documented hypersensitivity; obstetrical analgesia, increased intracranial pressure, respiratory depression, ulcerative colitis, Crohn disease, abdominal cramping and distention
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with head injuries since may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution postoperatively and with history of pulmonary disease (suppresses cough reflex); increased dosing levels, due to tolerance, may aggravate or cause seizures (even without prior history); adjust dose in renal insufficiency (do not use in severe renal dysfunction); normeperidine metabolite accumulation may induce CNS toxicity; monitor closely for morphine-induced seizure activity if prior seizure history
Fentanyl citrate
A synthetic opioid that is 75-200 times more potent and much shorter half-life than morphine sulfate. Has less hypotensive effects and is safer in patients with hyperactive airway disease than morphine because of minimal-to-no associated histamine release. By itself, it causes little cardiovascular compromise, although addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Highly lipophilic and protein-bound. Prolonged exposure leads to accumulation in fat and delays weaning process. Consider continuous infusion because of the short half-life of fentanyl.
Parenteral form is DOC for conscious sedation analgesia. Ideal for analgesic action of short duration during anesthesia and immediate postoperative period.
Excellent choice for pain management and sedation with short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.
After initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than q3h or q6h thereafter.
Transdermal form is used only for chronic pain conditions in opioid tolerant patients. When using transdermal dosage form, majority of patients are controlled with 72-h dosing intervals; however, some patients require dosing intervals of 48 h. Easily and quickly reversed by naloxone.
Adult
Emergency: 0.5-2 mcg/kg/dose IM/IV
Analgesia: 0.5-1 mcg/kg/dose IM/IV q30-60min
Transdermal for chronic pain: Apply a 25 mcg/h system q48-72h
Pediatric
<2 years: 2-3 mcg/kg/dose IM/IV q30-60min
2-12 years: 1-2 mcg/kg/dose IM/IV q60min
>12 years: Administer as in adults
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects of fentanyl when both drugs are used concurrently
Documented hypersensitivity; hypotension or potentially compromised airway where it would be difficult to establish rapid airway control
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation
Benzodiazepines
These agents facilitate the visualization and successful removal of the object. By binding to specific receptor sites, these agents appear to potentiate the effects of gamma-aminobutyrate (GABA) and to facilitate inhibitory GABA neurotransmission as well as other inhibitory transmitters.
Midazolam (Versed)
Shorter-acting benzodiazepine sedative-hypnotic useful in patients requiring acute and/or short-term sedation. Midazolam is also useful for its amnestic effects.
Adult
Conscious sedation:
Loading dose: 0.05-0.2 mg/kg IV over 2 min
Maintenance dose: Infuse 1-2 mcg/kg/min IV titrated to desired effect
Dosing range: 0.4-6 IV mcg/kg/min
Alternatively, 0.07-0.08 mg/kg IM
Pediatric
Sedation, anxiolysis, or amnesia: 0.1-0.15 mg/kg IV over 2-3 min
For more anxious patients, doses up to 0.5 mg/kg have been used
Intranasal versed may be used for pediatric sedation (up to 2 y of age); doses are 1-2 mg intranasally and limited by volume delivered
Sedative effects of midazolam may be antagonized by theophyllines; narcotics and erythromycin may accentuate sedative effects of midazolam due to decreased clearance
Documented hypersensitivity; preexisting hypotension; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, pulmonary disease, renal impairment, and hepatic failure
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Piperacillin and tazobactam sodium (Zosyn)
Anti-pseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.
Adult
3/0.375 g (piperacillin 3 g and tazobactam 0.375 g) IV q6h
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high-dose parenteral penicillins may result in increased risk of bleeding
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
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| Overview: Foreign Bodies, Rectum |
| Differential Diagnoses & Workup: Foreign Bodies, Rectum |
 Treatment & Medication: Foreign Bodies, Rectum |
| Follow-up: Foreign Bodies, Rectum |
| Multimedia: Foreign Bodies, Rectum |
| References |
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References
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Smith MT, Wong RK. Foreign bodies. Gastrointest Endosc Clin N Am. Apr 2007;17(2):361-82, vii. [Medline].
Clarke DL, Buccimazza I, Anderson FA, Thomson SR. Colorectal foreign bodies. Colorectal Dis. Jan 2005;7(1):98-103. [Medline].
Stack LB, Munter DW. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am. Aug 1996;14(3):493-521. [Medline].
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].
Janicke DM, Pundt MR. Anorectal disorders. Emerg Med Clin North Am. Nov 1996;14(4):757-88. [Medline].
Rosser C. Colonic foreign bodies. JAMA. 1929;39:368-369. [Medline].
Hellinger MD. Anal trauma and foreign bodies. Surg Clin North Am. Dec 2002;82(6):1253-60. [Medline].
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].
Further Reading
Keywords
object in rectum, rectal foreign body, rectal foreign object, rectal foreign bodies, rectal pain, rectal bleeding, rectal lacerations, rectal perforations, foreign body in the rectum
