Rectal foreign body

Rectal foreign body
Classification and external resources
Specialty emergency medicine
ICD-10 T18.5
ICD-9-CM 937
Radiograph of a male abdomen with a vibrator inside the rectum

Rectal foreign bodies are large foreign items found in the rectum that can be assumed to have been inserted through the anus, rather than reaching the rectum via the mouth and gastrointestinal tract. It can be of clinical relevance if the patient cannot remove it the way he or she intended. Smaller, ingested foreign bodies, such as bones eaten with food, can sometimes be found stuck in the rectum upon x-ray and are rarely of clinical relevance.

Rectal foreign bodies are a subgroup of foreign bodies in the alimentary tract.[1][2]

Frequency

There is no reliable data about the incidence of clinically meaningful foreign rectal bodies. It may have increased in the long term[3] as it is observed more often in recent times.[4]

The incident rate is significantly higher for men than for women. The gender ratio is in the area of 28:1.[3][5][6] A metastudy in the year 2010 found a ratio of 37:1. Median age of the patients was 44.1 years, with a standard deviation of 16.6 years.[7] Rectal foreign bodies are not an unusual occurrence in hospital emergency rooms.[8]

The first documented case dates from the 16th century.[9][10]

Causes

Reasons for foreign rectal bodies vary wildly, but in most cases they are of sexual or criminal motivation.[11] The foreign body was inserted voluntarily in the vast majority of cases. This especially includes sexually motivated behaviour, encompassing the majority of cases. Bodypacking, i.e. illegal transport of drugs within a body orfice (here: inside the rectum), is another – potentially – voluntary reason for insertion of foreign rectal bodies.[12] This includes attempts to transport objects like weapons, including knives, or ammunition. According to one study, sexual stimulation was responsible for 80% of clinically relevant foreign rectal bodies. About 10% of the cases were due to sexual assault.[13]

In rare cases, the patient inserted the object into the rectum without a way to remove it intending to receive attention and pity from doctors and nurses. This behaviour is categorized as Munchausen's syndrome.[9]

Another cause may be attempted self-treatment of diseases. One patient attempted to treat his chronic diarrhea by inserting an ear of maize into his rectum.[14] Another patient tried to soothe the itching due to his hemorrhoids (Pruritus ani) with a toothbrush. The toothbrush went out of control and disappeared inside his anus.[15]

Accidents or torture may cause an involuntary insertion of a foreign body.[16] A mercury medical thermometer inserted into the anus in order to measure the temperature, but broke off while inside, is an example of a foreign rectal body due to an accident.[17] Ancient Greece knew the Rhaphanidosis as a punishment for male adulterers. It involved the insertion of a radish into the anus. Many self-inserted rectal bodies are stated as accidentally by the patients due to feelings of shame.

There are several reasons that contribute to the jamming of rectal bodies inside the rectum. Many of the objects used for sexual stimulation have a conical tip in order to facilitate penetration, while the base is flat. Extraction by the user may be impossible if the base of the object passed the anus towards the rectum. In order to receive a stronger stimulation, the object may be inserted deeper than intended. In this case, the sphincter prevents, by mechanical means, the extraction of the foreign body.[18]

Objects

Type and size of the foreign rectal bodies are diverse and may exceed the anatomical-physiological imagination.[11]

Objects documented in literature include:

  • Razor, screw, screwdriver, small rolled tool bag (15×12 cm, including tools 620 g), hairpin, milk can opener
  • Fish bone, bone splinters
  • Different drug containers
  • Short staffs, such as a 27 cm long chair leg, a 19 cm long spade handle and a broken off broom handle, extension parts for a vacuum cleaner
  • Containers, sometimes exceeding 0.5 l in volume, e.g. sparkling wine bottles, bottles of Coca-Cola, jam pots, small beer glasses, cups
  • Spray can, light bulb, vacuum tube, candle
  • Table tennis ball, Boccia ball
  • Ammunition, firecracker
  • Cucumber, carrot, maize ear, banana, apples, onion, carved pieces of ginger
  • rolled newspaper
  • frozen pig tail
  • Vibrator, rubber rod, dildo
  • a knife sharpener
  • two flashlights
  • a wire spring
  • a toy car
  • a snuff box
  • an oil can with potato stopper
  • eleven different forms of fruit, vegetables and other foodstuffs
  • a jeweler's saw
  • a tin cup
  • a beer glass
  • spectacles, a suitcase key, a tobacco pouch and a magazine at the same time
  • plastic tooth brush case[11][18][19][20][21][22]

Not all objects are solid. In 1987, a case was documented of a patient who administered a cement enema. After it solified and impacted, the resulting block had to be surgically extracted.[23] Another extreme case occurred in November 1953. A depressed man inserted a 15 cm long cardboard tube into his rectum and tossed a lighted firecracker into the tube's opening, resulting in a large hole in his rectum.[24]

Diagnosis

Many patients feel ashamed during the anamnesis and provide information only reluctantly. This may lead to missing information that may be important during therapy. For the same reason, patients may not visit a doctor until very late. Trusting and sensitive care for the ashamed and uncomfortable patients is paramount for a successful therapy[25] and may be livesaving.[26]

Usually, several radiological images are recorded in order to pinpoint the precise place and depth of the foreign body. This is usually done by x-ray. Foreign bodies made from low-contrast material (e.g. plastics) may necessitate medical ultrasound or a CT scan.[25] Magnetic resonance imaging is contraindicated, especially if the foreign body is unknown. Foreign rectal bodies may penetrate deep into the colon, in certain circumstances up to the right colic flexure.[11]

An endoscopy, which may also be of use during therapy, facilitates the identification and localisation of the object inside the rectum.[27]

Information about the foreign body obtained in those ways are of high importance during therapy, as a perforation of the rectum or the anus is to be absolutely avoided.

Therapy

Endoscopic sling with the fragment of a glass bottle.

The therapeutic measures to remove the foreign body can be as diverse as the objects inside the rectum. In many instances, the foreign bodies consist of fragile materials, such as glass. Most patients wait for several hours or even days until they visit a doctor. Before they do, they often repeatedly try to remove the object themselves or by a layperson. This often worsens the situation for a successful extraction.

In most cases, the foreign body can be removed endoscopic. Vibrators, for example, can be often removed using a large sling usually used to remove polyps during coloscopy.[28] Smaller objects like a medical thermometer can be removed by a biopsy forceps.[29] A flexible endoscope can be of no help with large and jammed objects. It may be preferable to use rigid tools in those cases.[11]

There have been several cases where instruments used in child birth have proven their worth for the removal of those foreign bodies, such as the forceps[30] and suction cups.[31] Wooden objects have been retrieved with corkscrews and drinking glasses after filling them with plaster.[30][32] A spoon can be used as an "anchor" by leaving it inside the glass during the plaster filling, removing it together with the glass.[19] Light bulbs are encased in a gauze shroud, shattered inside the rectum and extracted.[19]

There have been successful cases using argon-plasma coagulation. The object in question was a green apple wraped in cellophane inside the rectum of a 44-year-old patient. The argon-beam coagulation shrunk the apple by more than 50%, enabling its removal. Previous extraction attempts using endoscopic tools failed due to the flat surface of the object.[33]

If the object is too far up, in the area of the colon sigmoideum, and cannot be removed using one of the above methods, bed rest and sedation can cause the object to descend back into the rectum, where retrieval and extraction are easier.[18]

In difficult cases, a laparotomy may be necessary. Statistically, this is the case in about 10 percent of patients.[11] The large intestine can be manipulated inside the abdominal cavity, making it possible for it to wander in the direction of the anus and be grabbed there. A surgical opening of the large intestines can be indication in very difficult cases, especially if the manipulation of the object may pose a serious health risk. This may be the case with a jammed drug condom.[27]

Anaesthesia

Mild cases may need a sedation at most. Local and spinal anaesthesia find common use. Difficult interventions may need general anaesthesia; surgical opening of the abdominal cavity or the colon require it. General anaesthesia can be beneficial for the relaxation of the sphincter.[11]

Aftercare

After the surgery, a sigmoidoscopy – a colonoscopy focused on the first 60 cm of the colon – is good practice in order to rule out possible perforation and injury of the rectum and the colon sigmoideum.[34] Stationary aftercare may be indicated.

Examples

Object Procedure Anaesthesia Source
Ball pen Polypectomy sling N.A. [35]
Water-filled balloon Punction N.A. [36]
Chicken bone Polypectomy sling N.A. [37]
Toothpick Polypectomy sling N.A. [38]
Apple in cellophane Defragmentation using APC none [33]
Glass bottle Biopsy forceps General anaesthesia [29]
Vibrator Polypectomy sling none [29]
Vial Sengstaken–Blakemore tube N.A. [39]
Vial Polypectomy sling N.A. [40]
Enema tip Polypectomy sling N.A. [40]
Vibrator Biopsy forceps N.A. [40]
Pencil Polypectomy sling N.A. [41]
Iron rod Two-channel endoscope and wires N.A. [42]
Bottleneck Foley catheter General anaesthesia [43]
Spray tank Achalasy balloon None [34]
Sponge-like toy ball Suction cup General anaesthesia [44]
Vibrator Forceps and anal dilation Local anaesthesia [45]
Vibrator Hooked tongs Local anaesthesia [46]
Bottle of aftershave Bone holding forceps with rubber feet Spinal anaesthesia [47]
Chicken bones Fingers None [48]
Aerosol-can cap Grasping forceps and anal dilation General anaesthesia [49]
Vase Filling with plaster General anaesthesia [50]
Glass container Extraction using plaster Spinal anaesthesia [51]
Glass container Tracheal tube Local anaesthesia [52]
Apple Two-handed manipulation Local anaesthesia [53]
Glass container Foley catheter General anaesthesia [54]
Glass bottle Suction cup General anaesthesia [25]
100-watt electric bulb Three Foley catheters N.A. [55]
Thermometer Biospy forceps General anaesthesia [29]
Vibrator transanal Kocher's forceps Local anaesthesia [29]
Bowling bottle (Bottle in the shape of a pin) Forceps General anaesthesia [29]
Perfume bottle manual Spinal anaesthesia [56]
Piece of wood manual General anaesthesia [57]
Toothbrush container Fogarty catheter N.A. [58]
Oven mitt Forceps, after anal dilation General anaesthesia [59]
Drainpipe forceps in childbirth General anaesthesia [30]
Pétanque ball Electromagnet General anaesthesia [60]
Carrot Myoma lifter N.A. [61]
Glass object Suction cup Spinal anaesthesia [31]
Rubber ball manual extraction after anal dilation General anaesthesia [62]
Wooden staff Two-handed anal dilation Spinal anaesthesia [62]
Bottle manual after anal dilation General anaesthesia [63]
Dildo Myoma lifter N.A. [64]
Light bulb Abdominal compression Spinal anaesthesia [65]

Daten nach[34]

APC = Argon beam-coagulation
N.A. = Not available

Possible consequences of a non-removed object

If the foreign body is too big to allow feces from the colon to pass, a mechanical ileus may occur. The distension of the rectum and the disruption of the peristasis reinforce this effect.

The foreign body may cause infections, destroying the intestinal wall. Depending on the location of the perforation, this may lead to a peritonitis due to the feces or an abscess in the retroperitoneal space.

Smaller objects that injure the intestinal wall, but do not perforate it, may be encapsulated by a foreign body granuloma. They may remain in the rectum as a pseudotumor without any further effects.

Complications

The most common – but still rare – complication is a perforation of the rectum caused by the foreign object itself or attempts to remove it. Diagnosed perforations are operated immediately by opening the abdomen and removal or suturing of the perforated area. In order to suppress infections, antibiotics are usually prescribed.[18] Often, a temporary ileostomy is necessary to protect the stitches.[13] After a contrast medium applied by an enema proves the complete healing of the perforated area, the ileostomy is reversed. This usually takes between three and six months. [66] Average hospitalization is 19 days.[18]

Medical literature describes some deaths due to rectal foreign bodies, but they are very rare and usually classified as autoerotic fatality. A 75-year-old patient died due to a rectal perforation caused by a mentally ill person using a cane.[67] Another middle-aged patient died due to a rectal perforation by a vibrator. The perforation was sutured and the patient received intensive medical care, but he contracted Acute Respiratory Distress Syndrome (ARDS) and systemic inflammatory response syndrome (SIRS) due to the trauma, resulting in multiple organ dysfunction syndrome (MODS) and death.[68] There is a paper describing a death after a perforation with a shoehorn.[69] The rectum has to be nursed after a surgical procedure until healing is complete. A 54-year-old man, who had been operated on twice in order to remove a foreign body (a cucumber and a parsnip), died due to a peritonitis after he inserted two apples into the rectum before the wound had healed.[19]

By oral intake

The other way for a foreign body to travel through the digestive system (after oral intake and passage through the entire intestines) happens very often, but is only rarely medically relevant. Other constriction, such as the esophagus, cardia, pylorus or ileocecal valve tend to cause issues with other organs, provided a foreign body is large enough to be an issue. Some foreign bodies may still pass those narrows and may cause medically relevant issues, i.e. toothpicks and bones.[2][3] Bones especially, i.e. from chickens, cause about half of all intestinal perforations.[48][70]

Plant-based food, especially seeds like popcorn,[71] watermelon, sunflower and pumpkin seed, may clump together inside the lower intestines to form bezoars. Those may grow too big for normal anal passage, thus becoming clinically relevant. This kind of rectal foreign body happens chiefly in children, especially in Northern Africa and the Middle East, where those seeds form an elemental part of the diet.[72][73] In very rare cases, seeds inside a bezoar may germinate inside the lower intestines or the rectum, causing a blockade.[74]

In veterinary medicine

Foreign rectal bodies are rare in veterinary medicine. A passage through the entire intestines, followed by a stay inside the rectum is – as with humans – rare.[75] Animals may have bezoars out of different materials, which may migrate to the rectum and cause problems.[76] Atypical foreign rectal bodies in animals of both sexes may be caused by sexual or sadistic abuse.[77]

Ig Nobel Prize

The Ig Nobel Prize was awarded in 1995 to David B. Busch and James R. Starling from Madison, Wisconsin for their 1986 article Rectal foreign bodies: Case Reports and a Comprehensive Review of the World’s Literature[56] (see List of Ig Nobel Prize winners).[78]

See also

References

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  74. ↑ F. Mahjoub u. a.: Invading plant material appearing as a colonic tumoural mass in a four-year-old girl. In: Trop Doct 39, 2009, S. 253–254. PMID 19762589.
  75. ↑ C. B. Webb u. a.: Rectal strictures in 19 dogs: 1997–2005. In: JAVMA. Band 43, 2007, S. 332–336. PMID 17975215
  76. ↑ N. D. Sargison u. a.: Intestinal obstruction in a blue-faced Leicester ram associated with a phytobezoar lodged at the pelvic inlet. In: Veterinary Record. Band 137, 1995, S. 222. PMID 7502475.
  77. ↑ H. M. C. Munro, M. V. Thrusfield: "Battered Pets": Sexual Abuse. In: Journal Of Small Animal Practice. Band 42, 2001, S. 333–337. PMID 11480898
  78. ↑ Improbable Research: Winners of the Ig® Nobel Prize.

Additional literature

Textbook

  • E. Stein: Proktologie: Lehrbuch und Atlas. Verlag Springer, 2002, ISBN 3-540-43033-4, S. 329f. , p. 329, at Google Books

Articles

  • G. Kasotakis, L. Roediger, S. Mittal: Rectal foreign bodies: A case report and review of the literature. In: International journal of surgery case reports. Band 3, Nummer 3, 2012, S. 111–115, ISSN 2210-2612. doi:10.1016/j.ijscr.2011.11.007. PMID 22288061. PMC 3267241.
  • J. E. Goldberg, S. R. Steele: Rectal foreign bodies. In: Surg Clin North Am. 90, 2010, S. 173–184. doi:10.1016/j.suc.2009.10.004 PMID 20109641
  • M. Paynter: Practice makes perfect. Rectal foreign bodies. In: Emerg Nurse. 15, 2008, S. 22–24. PMID 18372783

Original research

  • R. Flores-Suarez, J. Reyes-del Valle: Images in clinical medicine. A foreign body. In: The New England Journal of Medicine. Band 363, Nummer 18, Oktober 2010, S. 1748, ISSN 1533-4406. doi:10.1056/NEJMicm0707656. PMID 20979475.
  • E. J. van der Wouden, B. D. Westerveld: Extraction of a rectal foreign body using a custom-made giant snare. In: Endoscopy. Band 42 Suppl 2, 2010, S. E122, ISSN 1438-8812. doi:10.1055/s-0029-1244009. PMID 20306405.
  • D. Song, C. S. Chen u. a.: Nonoperative management for large rectal foreign body removal. In: Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. Band 13, Nummer 6, Juni 2011, S. e163–e164, ISSN 1463-1318. doi:10.1111/j.1463-1318.2010.02408.x. PMID 20846300.
  • P. Billi, M. Bassi, F. Ferrara, A. Biscardi, S. Villani, F. Baldoni, N. D’Imperio: Endoscopic removal of a large rectal foreign body using a large balloon dilator: report of a case and description of the technique. In: Endoscopy. Band 42 Suppl 2, 2010, S. E238, ISSN 1438-8812. doi:10.1055/s-0030-1255573. PMID 20931459.
  • R. Durai, D. Biradhar, P. C. Ng: Two port laparoscopic-assisted removal of a migrating rectal foreign body. In: Techniques in coloproctology. Band 14, Nummer 3, September 2010, S. 263–264, ISSN 1128-045X. doi:10.1007/s10151-009-0548-5. PMID 19997954.
  • S. Arora, H. Ashrafian, E. D. Smock, P. Ng: Total laparoscopic repair of sigmoid foreign body perforation. In: Journal of laparoendoscopic & advanced surgical techniques. Part A. Band 19, Nummer 3, Juni 2009, S. 401–403, ISSN 1092-6429. doi:10.1089/lap.2008.0242. PMID 19245310.
  • C. G. Ball, A. D. Wyrzykowski, P. Sullivan, D. V. Feliciano: Intussuscepted intestine through a rectal foreign body. (PDF; 186 kB) In: Canadian journal of surgery. Journal canadien de chirurgie. Band 52, Nummer 5, Oktober 2009, S. E191–E192, ISSN 1488-2310. PMID 19865554. PMC 2769092.
  • S. I. Andrabi u. a.: Extraction of a rectal foreign body – an alternative method. In: Ulus Travma Acil Cerrahi Derg. 15, 2009, S. 403–405. PMID 19669974
  • Y. I. El-Ashaal, A. K. Al-Olama, F. M. Abu-Zidan: Trans-anal rectal injuries. (PDF; 75 kB) In: Singapore medical journal. Band 49, Nummer 1, Januar 2008, S. 54–56, ISSN 0037-5675. PMID 18204770.
  • O. T. Dale, N. A. Smith, R. S. Rampaul: Tube abuse: a rectal foreign body presenting as chest pain. In: ANZ journal of surgery. Band 77, Nummer 12, Dezember 2007, S. 1131–1132, ISSN 1445-1433. doi:10.1111/j.1445-2197.2007.04339.x. PMID 17973680.
  • J. P. Lake u. a.: Management of retained colorectal foreign bodies: predictors of operative intervention. In: Dis Colon Rectum. 47, 2004, S. 1694–1698. PMID 15540301
  • W. C. Huang, J. K. Jiang, H. S. Wang, S. H. Yang, W. S. Chen, T. C. Lin, J. K. Lin: Retained rectal foreign bodies. In: Journal of the Chinese Medical Association. Band 66, Nummer 10, Oktober 2003, S. 607–612, ISSN 1726-4901. PMID 14703278.
  • W. Fabian: Rektumfremdkörper. Diagnostische und therapeutische Aspekte. In: Z Gastroenterol. 29, 1991, S. 131–133. PMID 2058232
  • J. R. Colthurst: How to remove a rectal foreign body. In: British journal of hospital medicine. Band 43, Nummer 5, Mai 1990, S. 329, ISSN 0007-1064. PMID 2364225.
  • N. K. Cooper: Rectal foreign body of record length? In: The Medical Journal of Australia. Band 2, Nummer 13, Dezember 1979, S. 702, ISSN 0025-729X. PMID 530209.
  • A. J. Buzzard, B. P. Waxman: A long standing, much travelled rectal foreign body. In: The Medical Journal of Australia. Band 1, Nummer 13, Juni 1979, S. 600, ISSN 0025-729X. PMID 492002.
  • J. E. Barone u. a.: Perforations and foreign bodies of the rectum: report of 28 cases. In: Ann Surg. 184, 1976, S. 601–604. PMID 984928
  • D. Smith: Rectal Foreign Body. In: California and western medicine. Band 51, Nummer 5, November 1939, S. 329, ISSN 0093-4038. PMID 18745388. PMC 1660156.
  • H. G. Pretty: An ink bottle in the rectum. In: Can Med Assoc J. 31, 1934, S. 302–303. PMID 20319640
  • W. F. Gillespie: A vaseline bottle in the rectum. In: Can Med Assoc J. 31, 1934, S. 302. PMID 20319639
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