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Visual diagnosis : rectal foreign body : a case study
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Permanent Link: http://ufdc.ufl.edu/AA00008940/00001
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Title: Visual diagnosis : rectal foreign body : a case study
Series Title: International Journal of Emergency Medicine
Physical Description: Archival
Language: English
Creator: Desai, Bobby
Publisher: BioMed Central
Publication Date: 2011
 Notes
Abstract: We present a case that is occasionally seen within emergency departments, namely a rectal foreign body. After presentation of the case, a discussion concerning this entity is given, with practical information on necessity of an accurate and thorough history and removal of the object for clinicians.
General Note: Publication of this article was funded in part by the University of Florida Open-Access publishing Fund. In addition, requestors receiving funding through the UFOAP project are expected to submit a post-review, final draft of the article to UF's institutional repository, IR@UF, (www.uflib.ufl.edu/ufir) at the time of funding. The Institutional Repository at the University of Florida (IR@UF) is the digital archive for the intellectual output of the University of Florida community, with research, news, outreach and educational materials
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Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution.
Resource Identifier: doi - 10.1186-1865-1380-4-73
System ID: AA00008940:00001

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CASEREPORT OpenAccessVisualdiagnosis:Rectalforeignbody:Aprimerfor emergencyphysiciansBobbyDesaiAbstractWepresentacasethatisoccasionallyseenwithinemergencydepartments,namelyarectalforeignbody.After presentationofthecase,adiscussionconcerningthisentityisgiven,withpracticalinformationonnecessityofan accurateandthoroughhistoryandremovaloftheobjectforclinicians.CaseA39-year-oldmalepresentedtotheEmergencyDepartmentwithvaguecomplaintsofabdominalpainandconstipation.Hestatedthattheabdominalpainwasdull andcrampyinnatureandgeneralizedindistribution. Furthermore,hestatedthathehadnothadabowel movementin2days,thoughhefeltasifhehadtohave one.Hedeniedconstitutionalcomplaintsoffevers, chills,nausea,andvomiting,anddeniedurinarycomplaintsaswell. Thepatient svitalsignswere:temperature37.2C, pulse87beatsperminute,respiratoryrateof20per minute,andbloodpressure130/84mmHg.Thepatient wasawake,alert,andorientedtotime,person,and place.Hishead,neck,cardiovascular,respiratory,and neurologicexamswerealldocumentedaswithinnormal limits.Hisabdominalexamrevealedaflatabdomen,diffuselytenderwithbowelsoundsinallfourquadrants. Thephysiciannotedapalp ablemassintheleftlower quadrant.Uponfurtherexamination,themassfelt very hard andhadan oblong shapeaccordingtothephysiciannotes.Thepatientwassubsequentlyre-questioned aboutafamilyhistoryofcancer,whichthepatient denied.Thephysiciansubsequentlyorderedbasic laboratorytestsandanabdominalX-ray.TheAPand lateralX-raysareshowninFigures1and2. AfterobtainingtheX-rays,thephysicianpresentedthe X-raystothepatientandaskedhimwhattheobject was.Accordingtodocumentation,thepatientreplied thathedidnotknow.Thepatientwassubsequently placedintheleftlateraldecubituspositionandan anoscopeinserted.Theobjectcouldnotbevisualized, andthereforenoattemptwasmadetoremoveit.Generalsurgerywasconsultedtoseethepatientand decidedtotakehimtotheoperatingroomforremoval. Thepatientagreedtothis. Theobjectwasnotedtobetheextensionarmofa vacuumcleaner.Itwasremovedaccordingtonoteswith somedifficultyandthepatientwasadmittedtothehospitalforobservationandintravenousantibiotics.The patientwassubsequentlydischarged2dayslaterin excellentcondition.Uponsocialworkdischarge,hewas againaskedhowthatapparatusmanagedtobeplaced whereitwas.Thepatientvehementlydeniedsexual assaultorabuse,andinsistedhedidnotknowhowit cametobethere.Hemetnocriteriaforamandatory psychiatrichold,butwasofferedtheservicesofpsychiatry,whichherefused.DiscussionThemajorityofrectalforeignbodiesseeninpractice todayarearesultofdeliberateinsertionintotheanal canal[1,2].However,somesharprectalforeignbodies thathavetraversedentiredigestivetractmaybecome impactedwithintherectum,thoughthisisfarlesscommon.Thesemaytypicallypresentacutelywithsignsand symptomsoftrauma,suchasbleedingandperforation. Inthoseinstanceswheretheobjecthashadsomedelay eitherinpresentationordiagnosis,thepatientmaypresentwithsignsandsymptomsofinfection-fever,chills, andsepsis.Anabscessislikelytobefoundinthese patients[3]. Themajorityofrectalforeignbodieshaveinserted purposefullybythepatient themselvesorbyasexual partner.Theseforeignbodiesareusuallybluntandtake Correspondence:bdesai@ufl.edu DepartmentofEmergencyMedicine,UniversityofFlorida,POBox100186, Gainesville32610,FL,USADesai InternationalJournalofEmergencyMedicine 2011, 4 :73 http://www.intjem.com/content/4/1/73 2011Desai;licenseeSpringer.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttribution License(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium, providedtheoriginalworkisproperlycited.

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theshapeofmalegenitalia[4,5].Patientsthatrepeatedly placethesetypesofobjectswithintheanalcanalover timefindthatduetotheincreasinglaxityoftheirrectal tone,theycaninsertobjectsofahighercaliber.These maybedifficultforthepatienttoremove.Victimsof sexualassaultmaypresentwithobjectsofvaryingcaliber,andthesemaynotnecessarilybeofablunttype. Thesepatientsrequirecarefulexaminationtoensure thatperforationhasnotoccurred.Drugmuleshave beenknowntoeitherswallowlatexballoonsordirectly placethemwithintheanus. Duetothesensitivenatureofthecomplaint,itis occasionallydifficulttoelicitahistoryofthepresentillness.Furthermore,patientsmaybetooembarrassedto presentearlytoanEmergencyDepartment.Common presentingcomplaintsincludedabdominalpain,rectal pain,rectalbleeding,andconstipation.Forthose patientswhomayhaveabowelperforation,signsand symptomsofthismaybepresent,includingsevere guarding,reboundtenderness,andfever,andthese patientsmaypresentseptic[6]. Thephysicianshouldmake everyefforttoensurethe patientfeelscomfortabledu ringthehistorybecauseof thenecessityofgainingaccurateinformationaboutthe foreignbody.Informationshouldbesoughtastothe objectsapproximatesize,shape,material,lengthoftime sinceinsertion,andanyattemptsatremoval. Forexamination,thepatientshouldbeplacedin eitherthelateraldecubitusp ositionorlithotomyposition.However,ifthecliniciansuspectssharpforeign objects,aplainabdominalX-rayshouldbeobtained firstpriortoexaminationtolessenthelikelihoodof inadvertentinjurytoeitherthepatientorclinician.If sharpobjectsarenoted,theexamshouldbedeferred andsurgeryconsulted.Furthermore,iftherearesigns andsymptomsofbowelperforation,attemptsatremoval shouldceaseandsurgeryshouldbeconsultedemergentlyaswell.PlainabdominalX-raysareindicatedin almostallcases;CTscansshouldbereservedforthose withpotentialsepsisorequivocalperitonealsigns[3]. Hollowobjectsmayhaveagaspatternintheirgeneral shape.Radiolucentobjectsmayrequiretheuseofrectal contrast;however,inthesecasescomputedtomography maybethebettermodalitytodefinitivelydiagnosethe foreignbody. Ifthisisnotthecase,theexaminationmayproceed withageneralsurveyoftheanalarea,notingfissures, excoriations,lacerations,andhemorrhoids.Adigitalrectalexamfollowedbyanoscopymayrevealtheobjector signsoftraumaproximaltotheanalverge. Treatmententirelydependsonthelocationoftheforeignbody.Low-lyingforeignbodiesbydefinitionare withintherectalampulla,c anoftenbepalpated,and potentiallycanberemovedintheemergency Figure1 APview Figure2 Lateralview Desai InternationalJournalofEmergencyMedicine 2011, 4 :73 http://www.intjem.com/content/4/1/73 Page2of3

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department[7].High-lying objectsusuallyrequireconsultationasthesearelocatedproximaltotherecto-sigmoidjunctionandrequireendoscopyforremoval[7]. Duetothecurvatureofthesigmoid,theseobjectstypicallyareunabletopassbeyondthisarea[8]. Priortoattemptingremoval,thephysicianshouldconsidermedicationwithagentsthatrelaxnotonlythe patient,buttheanalsphincteraswell.Ifthepatientcan toleratetheprocedurewithoutproceduralsedation,they maybeabletoassistthephysicianbyperformingthe Valsalvamaneuver[9].Regionalanesthesiamaybeconsideredusingaperianalblock,thoughmostemergency physicianswillhavelimitedexperiencewiththis[10]. Removalmaybeaccomplishe dbyhavingthepatient performtheValsalvamaneuverwhilethephysician appliespressuretothesuprapubicareawhilesimultaneouslytryingtograsptheforeignbodythroughthe anus.Eitherafingerorforcepsmaybeused;forceps wouldbeidealiftheobjecthasagraspableedge.To improvevisualization,ananoscopeorothertypeof retractormaybeused.Iftheobjectcannotberemoved inthisfashion,aFoleycathetermaybeused.Astandard Foleyusuallycannotbeusedbecauseofitsinherent flexibility,anditoftentimesmaybedifficulttopassthe Foleypasttheobjectbecauseoftheobject sdiameteror length.Therefore,itisrecommendedthatathree-way Foleycatheterwithalargeballoonbeused.Awelllubricatedcatheterisadvancedpasttheobjectandthe ballooninflated.Ifathree-wayFoleyisunavailable,a small-diameterendotrachealtubecanbeused.Ineither case,thecatheterwiththeballooninflatedortheendotrachealtubeisthenslowlywithdrawn.However,care mustbetakennottoforceeithertubepasttheobject becauseoftheriskofiatrogenicperforation.TwoFoley catheterscanbeutilizediftheobjecttapersnearitsdistalend. Complicationsofremovalincludehemorrhage,perforation,andmucosaltears[3].Mostexpertsagreethat routinesigmoidoscopyshouldbeundertakenforall patientssubsequenttoforeignbodyremoval[6,7].The emergencyphysicianshouldobservethepatientfor signsofperforationafterremoval.Thelengthofobservationentirelydependsonpatientpresentationandsubsequentclinicalstatuspost-extraction.ConsentWritteninformedconsentwasobtainedfromthepatient forpublicationofthiscasereportandanyaccompanyingimages.Acopyofthewrittenconsentisavailable forreviewfromtheEditor-in-Chiefofthisjournal.Authors contributions BDwrote,edited,andrevisedtheentirereport. Competinginterests Theauthordeclaresthattheyhavenocompetinginterests. Received:29July2011Accepted:7December2011 Published:7December2011 References1.LyonsMF,TsuchidaAM: Foreignbodiesofthegastrointestinaltract. Med ClinNorthAm 1993, 77(5) :1101-1114. 2.MoreiraCA,WongpakdeeS,GennaroAR: Aforeignbody(chickenbone) intherectumcausingextensiveperirectalandscrota1abscess:reportof acase. DisColonRectum 1975, 18(5) :407-409. 3.AndersonKL,DeanAF: Foreignbodiesinthegastrointestinaltractand anorectalemergencies. EmergMedClinNAm 2011, 29 :369-400. 4.FryRD: Anorectaltraumaandforeignbodies. SurgClinNorthAm 1994, 74(6) :1491-1505. 5.ClarkeDL,BuccimazzaI,AndersonFA, etal : Colorectalforeignbodies. ColorectalDis 2005, 7(1) :98-103. 6.GoldbergJE,SteeleSR: Rectalforeignbodies. SurgClinNorthAm 2010, 91(1) :173-184. 7.EftaihaM,HambrickE,AbcarianH: Principlesofmanagementofcolorectal foreignbodies. ArchSurg 1977, 112(6) :691-695. 8.BaroneJE,SohnN,NealtonTF: Perforationsandforeignbodiesofthe rectum:reportof28cases. AnnSurg 1976, 184(5) :601-604. 9.JohnsonSO,HartranftTH: Nonsurgicalremovalofarectalforeignbody usingavacuumextractor.Reportofacase. DisColonRectum 1996, 39(8) :935-937. 10.WigleRL: Emergencydepartmentmanagementofretainedrectalforeign bodies. AmJEmergMed 1988, 6(4) :385-389.doi:10.1186/1865-1380-4-73 Citethisarticleas: Desai: Visualdiagnosis:Rectalforeignbody:A primerforemergencyphysicians. InternationalJournalofEmergency Medicine 2011 4 :73. Submit your manuscript to a journal and bene t from:7 Convenient online submission 7 Rigorous peer review 7 Immediate publication on acceptance 7 Open access: articles freely available online 7 High visibility within the eld 7 Retaining the copyright to your article Submit your next manuscript at 7 springeropen.com Desai InternationalJournalofEmergencyMedicine 2011, 4 :73 http://www.intjem.com/content/4/1/73 Page3of3