Rectal Foreign Bodies Treatment & Management

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.

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.

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 Minimize the cross-sectional size of the foreign body (turn it if necessary so that it is withdrawn the long-ways).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.

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.