Foreign Body in The Rectum

Abstract

Turkish Abstract

Introduction

Foreign body in the rectum is not common a rare clinical presentation that can be seen in emergency room (ER). These may either be ingested by an oral intake or a trans-anal route. It is a rare possibility that an orally ingested object can go through the ileo-cecal valve and then stuck in rectum. Generally in all the cases penetration through the rectum is the most common route. This is commonly seen as a consequence of an attempt of a sexual satisfaction or as a result of a sexual insult in the middle aged males ¹. These objects can be fruits, vegetables, wooden objects, iron sticks and even bottles. Insisting on the especially removal of the glass like foreign bodies trans-anally may worsen the current situation; therefore we should not hesitate in giving the laparotomy decision.

Case Report

A fifty-year-old male patient admitted to the ER with  rectal pain and rectal bleeding. In his history he said that he fell on a lamp bulb and that the bulb went through his anus. He admitted to the ER 12 hours after the accident. In the physical examination there was tenderness in the lower abdomen. In the perineum examination laceration and bleeding around the anus were seen. The tetanus vaccination and antibiotic were given. The anal sphincter tonus was declined in the digital rectal examination. The foreign body was not palpable. His blood pressure was 110/80, pulse was 85/min, haemoglobin level was 10 mg/dl and his other laboratory values were in normal range. The foreign body was seen in the pelvis in the abdominal x-ray (Figure 1). Computerized tomography (CT) was taken to decide on the integrity and the composition of the foreign body (Figure 2). Free air or fluid was not detected in the investigations. There was no free fluid or air in the abdomen in the imaging studies.

Figure 1 Abdominal X-Ray

Figure 2 Abdominal CT

He was hospitalized, taken into the intensive care unit (ICU) where prophylactic antibiotic was started and a bed side rectoscopy was performed. Because of the sphincter damage due to the trauma rectum could not be well inflated and rectoscopy was suboptimal. The broken tip of the piece of the glass was seen. It was stuck and could not be moved. Trans-anal exploration under sedation was planned. After the informed consent form was taken from the patient in lithotomy position exploration was done. The object was found to be in the upper parts of the rectum. The laparotomy under general anaesthesia decision was taken because of the risk of the bleeding from the sharp edges of the broken glass. In the laparotomy more than half of the foreign body was seen above the peritoneal reflexion. In the pelvic region especially in the pre-sacral area self limiting haematomas were seen. Through the anus the object was tried to be pushed over the reflexion into the sigmoid colon but it was not successful. After that a 6-7 cm vertical incision to the rectum covering the foreign body was done (Figure 3), and the object was removed (Figure 4).

Figure 3 Foreign body removal

Figure 4 Lamp bulb seen intra-operatively

Presence of hematoma in the pre-sacral area below the peritoneal reflection brought out the suspicion of the rectum perforation, also the damage and the incontinence of the anal sphincter urged us to decide to perform a diverting loop colostomy.

Discussion

Rectal foreign bodies are reported in all age and ethnic groups. More than two third of the cases are male, generally in the 30 and 40 years age group ² . In half of these cases the patients insert  objects to gain  sexual satisfaction. Others are 25% to perform a prostate massage, to treat constipation and haemorrhoids, 12% as a result of a sexual assault, accidents in  9%, and rarely in psychiatric patients. Forty-two percent of these are daily used objects in the houses, 16% of these are sex toys, 14% are self care objects, 6% are fruits and vegetables, 5.5% are sporting goods ³. As we can understand from these numbers we can come across with a lot of types of foreign bodies. For the treatment the important thing for us is the type, size, shape, number and the location of the foreign body.

For the diagnosis a good history taking, physical examination and abdominal x-rays are generally enough. Generally patients say that the foreign bodies penetrate thorough the anus accidentally. Our patient said in his history that there is a foreign body in his anus, and his attempts to remove ended up in breaking of this lamp. In these situations water soluble contrast colographies and computerized tomographies may be used for the detection of the broken pieces of glass and to evaluate rectum.

CT also helps to see the free perforation or free liquid in the abdomen. Most of the patients try to remove the foreign bodies themselves and in some cases they could be successful. But sometimes these attempts may cause  further ascending of the foreign body or they may break the foreign body in the lumen and  this may cause an injury at the wall of the rectum ⁴. In the literature it is reported that most of the foreign bodies may be removed trans-anally under the sedation.

Generally in  literature most of the foreign bodies are said to be removed trans-anally under sedation. The objects longer than 10 cm, solid and sharp, located below the sigmoid colon and those that are stuck for 2 days or more cannot be removed trans-anally ⁵. In cases where there is a perforation, peritonitis findings and/or failure of the trans-anal removal, laparoscopy or laparotomy should be performed.  In our case rectoscopy was done but it was not successful.

It should not be insisted on removing the broken lamp bulb, glass etc. in the rectum trans-anally. It should be kept in mind that this could worsen the current situation; we should not hesitate in giving the decision of laparotomy.

References

1. Atila K, Söklem S,  Astarcıoğlu H. Rektumda yabancı cisim: Dört olgu sunumu. Ulus Travma Derg. 2004;10(4):253-6.
2. Coskun A,  et al. Management of rectal foreign bodies. World J Emerg Surg.  2013 8:11.
3. Kurer MA, et al. Colorectal foreign bodies: A systematic review. Colorectal Dis. 2010; 12:851-61.
4. Caliskan C, et al. Foreign bodies in the rectum: An analysis of 30 patients. Surgery Today.  2011; 41(6): 795-800.
5. Lake JP, et al. Management of retained colorectal foreign bodies: Predictors of operative intervention. Dis Colon Rectum.  2004;47:1694?8.