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Michael Su MD CCFP(EM) Emergency Medicine Grand Rounds January 29 th, 2009 Rectal Foreign Bodies and Other Weapons of Ass Destruction II: Return of the.

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Presentation on theme: "Michael Su MD CCFP(EM) Emergency Medicine Grand Rounds January 29 th, 2009 Rectal Foreign Bodies and Other Weapons of Ass Destruction II: Return of the."— Presentation transcript:

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2 Michael Su MD CCFP(EM) Emergency Medicine Grand Rounds January 29 th, 2009 Rectal Foreign Bodies and Other Weapons of Ass Destruction II: Return of the Red Eye

3 Accreditations/special thanks to: Dr. Eric Grafstein, MD,FRCP Dr. Rick Walker, MD FRCP Ms. Monica Fredborg, RTR

4 The following hairstyle is associated with: A) rectal foreign bodies B) a C) a + b D) all of the above

5 Objectives Review Epidemiology of Foreign Bodies Structural Issues History and physical exam Review Management Issues Around Removal Special cases Complications Legal implications Skill-testing session: What am I

6 Case 1: A 34 year old male presents to the ED with a vibrator lodged firmly in his rectum. He tells you that he tried to get it out, his girlfriend tried to get it out, and that everybody there tried to get it out. On exam he is in no distress, vitals are stable. Abdominal exam is unremarkable. On rectal exam you can just feel the tip of the vibrator. You think this might be retrievable in the ED with procedural sedation. As the young female respiratory therapist leaves the room for equipment, the patient says to you that he should probably scratch her off his someone Id like to date list, and he then informs you that he had Kolbasa sausage the night before. As you reflect on the case you wonder why they didnt teach you about this in medical school, and that you believe there is still time to reassign the patient to Dr. Abbi on REDIS…

7 Search Methodology Medline current Wolters Kluwer | OvidSP

8 Results of search 240 articles found 175 identified as possibly relevant Abstracts reviewed (large number of case studies, no RCT identified) bibliographies Expert consultation with ….

9 Google search weapons of ass destruction items retrieved in 0.2 seconds

10 Epidemiology

11 Incidence and prevalence Mostly case series, with ranges of 8 to 101 cases on average over 5 year periods, Calgary data, St. Pauls data male predominate 35:1 ? Bimodal distribution (30s and 60s) although all ages included, all data based on very small sample sizes Incidence is increasing Presentation: typically 6-48 hours after transanal insertion; 48 hours-3 months after orally ingested rectal FB Singaporewella RM et al. Use of Endoscopic Snare to Extract a Large Rectosigmoid Foreign Body with Review of Literature. Surg Laparosc Endoxc Percutan Tech 2007;17:

12 Incidence and prevalence UpToDate Online 16.3,

13 Maybe we should ask the registrants at this conference…

14 Calgary Health Region

15 Rectal Foreign Bodies at SPH N = 28

16 Anatomy

17 Netter, Atlas of Human Anatomy, 1989

18 Anatomy Netter, Atlas of Human Anatomy, 1989

19 Anatomical Considerations Anal canal 4 cm long, rectum 12 cm long beginning at 3 rd sacral vertebra Rectum covered with peritoneum for first two-thirds of its course Arterial and venous supply of rectum: superior, middle, and inferior hemorrhoidal arteries and veins Lymphatics: inguinal lymph nodes, external iliac or common iliac lymph nodes Anal canal lined by stratified epithelium, highly sensitive to pain; rectum lined by mucosa, insensitive to pain Once above levator ani, muscles and conical shape of the pelvis cause FBs to rise above the pelvic brim; FB usually becomes impacted at the sacral hollow where rectum forms a sharp anteriorposterior curve Irizarry E et al: Rectal sexual trauma including foreign bodies. International Journal of STD & AIDS; 7: Brenner BE, Simon RR: Anorectal emergencies. Ann Emerg Med 12: , June 1983

20 Physiological Considerations 4 groups of muscles involved in anorectal physiology: 1. external sphincter: striated muscle, voluntary control, prevents defecation even when urge present 2. internal sphincter: prevents stool from entering anus, maintains stool in rectum causing rectal ampulla to dilate 3. puborectalis: reflexively intitiates defecation in a propulsive wave, provided external sphincter relaxed 4. levator ani: finishes expulsion of stool Brenner BE, Simon RR: Anorectal emergencies. Ann Emerg Med 12: , June 1983

21 Circumstances of Rectal Foreign Body Introduction 1. diagnostic or therapeutic: thermometer, barium, rectal tube, disposable enema tip, irrigation catheters 2. self-administered treatment to alleviate symptoms of anorectal disease eg. Insertion of broomstick to relieve itching or to reduce prolapsed hemorrhoids 3. criminal assault 4. autoeroticism 5. accidental introduction Eftaiha M et al: Principles of Management of Colorectal Foreign Bodies. Arch Surg 112: ,1977

22 Classification

23 Many different characteristics (shape, composition, surface contour, orientation) influence ultimate method of removal Initial approach: 1. low-lying: palpable in the rectal ampulla 2. high-lying: in or proximal to the rectosigmoid junction

24 Classification of FB Only limitation of objects used is the capacity of the rectum to accommodate them Busch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the Worlds Literature. Surgery 1986; 100(3): 512-9

25 Classes of Foreign Bodies Glass or ceramic Bottle or jar Bottle with attached rope Glass or cup Light bulb Tube Food Apple Banana Carrot Cucumber Onion Parsnip Plantain (with condom) Potatoe Salami Turnip Zucchini Wooden Axe handle Stick or broom handle Miscellaneous Kitchen Devices Dull knife Ice pick Knife sharpener Mortar & pestle Spatula (plastic) Spoon Tin cup Inflated device Balloon Balloon attached to cyl Condom Bicycle inner tube Balls Baseball Tennis ball Bocce ball Misc Containers Candlebox Snuffbox Baby powder can Misc tools Candle Flashlight Iron rod Pen Rubber tube Screwdriver Toothbrush Wire spring Busch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the Worlds Literature. Surgery 1986; 100(3): 512-9

26 ...Miscellaneous Bottle cap Cattle horn Frozen pigs tail Kangaroo tumor Plastic rod Stone Toothbrush holder Toothbrush package Whip handle Gerbil Busch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the Worlds Literature. Surgery 1986; 100(3): 512-9

27 ...Collections 2 glass tubes 72-1/2 Jewellers saw Oil can with potatoe stopper Piece of wood, and peanut Umbrella handle and enema tubing 2 Glasses Phosphorous match ends (homicide) 402 stones Toolbox 2 bars soap Beer glass and preserving pot Lemon and cold cream jar 2 apples spectacles, suitcase key, tobacco pouch, magazine Busch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the Worlds Literature. Surgery 1986; 100(3): 512-9

28 Age Distribution Busch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the Worlds Literature. Surgery 1986; 100(3): 512-9

29 World Records

30 What is the longest documented rectal FB retrieved?: 14 inch piece of sandfilled bicycle inner tubing (close second 30 cm x 2.5 cm garden hose (colonscope passed through lumen of FB with hose) Obrador A et al. Colonoscopic Removal of a Long Piece of Garden Hose. Gastrointestinal Endoscopy 1988; 34(3):286-7

31 What is the widest documented rectal FB retrieved?.85 kg stone, oval in shape, 23.3 cm in circumference, 12 x 8.6 x 8.8 cm Removed with bone forceps Sachdev YV et al. An Unusual Foreign Body in the Rectum. Diseases of the Colon and Rectum ;3:

32 What is the best travelled rectal FB on record? Case Report: bachelor, mid 60s presented with severe anal pain after vigorous extracurricular activities the night before. Freely mobile palpable abdominal mass, painful rectal exam Referred for surgical opinion, declined as patient stated he was on a world tour Returned 6 months later for FB removal, 20 cm x 2.5 cm vibrator removed Longest recorded in situ FB case recorded Also best travelled Buzzard AJ et al. A Long-Standing, Much Travelled Rectal Foreign Body. Med.J. Aust., 1979, 1:600

33 Approach

34 Management of Rectal Foreign Bodies Singaporewella RM et al. Use of Endoscopic Snare to Extract a Large Rectosigmoid Foreign Body with Review of Literature. Surg Laparosc Endoxc Percutan Tech 2007;17:

35 History How did it happen Description of the circumstances surrounding the injury is usually suspicious Usually attributed to some type of accident or therapeutic misadventure ~1/3 admit to transanal insertion, 2/3 complain of vague anal pain Always be attuned to the possibility of physical abuse Boon-Swee Ooi et al. Management of Anorectal Foreign Bodies: A Cause of Obscure Anal Pain. Aust.N.Z.J. Surg.(1998)68,

36 History Case 1: the garden story Case 2: baseball in rectum 49 y/o male, presented with urinary retention and round firm object firmly lodged in rectum He and his partner had celebrated a World Series victory of the Oakland Athletics by placing a baseball into his rectum because he was oversexed Case 3: vaseline jar in rectum 57 y/o male, massaging his rear end with a jar of petroleum jelly to relieve a bothersome itch He coughed and sneezed at the same time, caused the rectum to relax and the jar to slip in as he sat down at the edge of the bed McDonald PT et al. An Unusual Foreign Body in the Rectum-A Baseball: Report of a Case. Dis Colon Rectum 1977; 20:1 56-7

37 History: A case of atypical chest pain Case: 71 y/o male, admitted to CCU with chest pain radiating to epigastrium, associated with vomiting, no abd pain Rectal FB risk factor on hx: admitted for urethral FB extraction 2 years previously Eventual hx came out, FB removed in OR under spinal 48 hours, intra-abdominal sepsis, peritonitis Perforated sigmoid colon, Hartmanns procedure, discharged 6 weeks later Dale OT et al. Tube abuse: a rectal foreign body presenting as chest pain. ANZ Journal of Surgery 2007; 77(12):1131-2

38 History: A case of atypical chest pain Dale OT et al. Tube abuse: a rectal foreign body presenting as chest pain. ANZ Journal of Surgery 2007; 77(12):1131-2

39 Physical Exam Focus on abdomen (to exclude perforation),inspection of anus, and careful digital exam Unusual avoidance of pelvic/anal exams Rectal/vaginal lacerations, bleeding, scars Anal fissures, fistulas Mucosal irritation (secondary to soaps, shampoos used as lubricants) Foul-smelling anal or vaginal discharge Localized discomfort to anus, vagina The vibrating umbilicus sign (Mike Betzner) 25 y/o male, loss of vibrator, deep central abdominal ache, vibrating umbilicus, and a gentle hum Attempt to deliver the vibrator too painful but manipulation resulted in mechanism being turned off, with resolution of pain and vibrations Jackson D et al. Vibrating Umbilicus. BMJ. 2/

40 Laboratory & Imaging

41 Investigations: ECG Hammond EJ et al., An Unusual ECG. Anaesthesia, 2001, 56(4):402.

42 Anal Fibrillation

43 Role of Imaging Define the foreign body Free air? Is there only one? Timing? To provide content for emergency medicine grand rounds

44 Radiographic Detection of Foreign Bodies Classification 1. highly radiopaque: high physical density, low photographic density on radiograph (bullet fragments, surgical clips, orthopedic hardware 2. slightly radiopaque: physical density slightly higher than body tissues (e.g. glass, aluminum, chicken bones, some plastics) 3. body density: no visible difference in photographic density between these materials and body tissue (e.g. thorns, some plastics, and wood in situ for more than 48 hrs) 4. radiolucent: lower physical density than body tissue, produce a greater photographic density than body tissue (e.g. wood within a short period of injury, some plastic materials, materials containing air) Radiopacity proportional to density or weight per unit volume of the material examined Denser material absorbs more photons Fodor J et al. The Radiographic Detection of Foreign Bodies. Radiological Technology /5:361-70

45 Radiolucent Foreign Body Objects Lee KF et al. Radioluscent foreign body visible on plain radiography. Can J Surg ;3: 87-88

46 Radiolucent Foreign Body Objects Lee KF et al. Radioluscent foreign body visible on plain radiography. Can J Surg ;3: 87-88

47 Radiographic Detection of Foreign Bodies Misconceptions: glass, aluminum, wood Glass: all glass normally encountered radiopaque compared to body tissue Aluminum: metal of low physical density, may be very difficult to detect radiographically Wood: dry wood lower physical density than body tissues, within hours becomes water logged and equivalent in density to body tissue Fodor J et al. The Radiographic Detection of Foreign Bodies. Radiological Technology /5:361-70

48 Radiographic Detection of Foreign Bodies Contrast studies: foreign bodies present as filling defects in the contrast-filled structure. gastrograffin enema Computed Tomography: can detect differences in tissue density as low as 0.5% Ultrasound

49 Removal

50 ED Principles of Removal Exclude perforation Object must be able to be removed transanally High-lying bodies must be convertible to low-lying bodies Planned approach to removal; equipment for position conversion and extraction at bedside No ED removal if FB fragile and there is risk of bowel damage if it fragments Wigle RL. Emergency Department Management of Retained Rectal Foreign Bodies. Am J Emerg Med 1988;6:

51 ED Principles of Removal Minimize cross-sectional are of removal device Simple is better: most successful FB removed with some type of snare, encasing forcep, or piercing tenaculum Remove under direct vision Overcome the suction effect Limit time: no more than 30 minutes Wigle RL. Emergency Department Management of Retained Rectal Foreign Bodies. Am J Emerg Med 1988;6:

52 The Difficulty with Removing Rectal FB FB usually has a smooth surface, difficult to grasp Often very friable (e.g. vegetable) or very hard (glass) Mucous/blood make traction and visualization difficult Anal sphincter may be is spasm or oedematous Rectal mucosa may be oedematous or bulging Curve of sacrum tends to hold the lower end of the FB away from the anus Blunt end of the FB usually presents caudally High-lying objects sometimes trapped either by rectosigmoid junction or the iliac spines Negative pressure may develop above the FB when traction is attempted, creating a suction effect on the FB Couch CJ et al. Rectal FB. Med J Aust 1986;144:

53 Palpable Rectal Foreign Bodies Trial of removal Post extraction management SuccessfulUnsuccessful Referral to General Surgery

54 Removal of the Palpable Foreign Body

55 Local anesthetic written about but not used Sedate the patient well (propofol) Relax patient Relax anal sphincter Lithotomy position: helps to ease the passive tension of the abdominal wall muscles; heads up position assists with gravity Get a second pair of hands to apply pressure on the abdominal wall to prevent retrograde migration of FB. Not likely uncharted waters. Get a small pair of hands, ideally not yours. Be prepared to invest some time

56 Abdominal Pressure or Valsalva Maneuver

57 Removal Equipment & Techniques

58 Specific Tools of your Arse-nal Digital removal Parks retractors, vaginal speculum Tenaculum/Ringed Forceps Labour and Delivery Forceps Foley catheters, endotracheal tubes, Sengstaken-Blakemore tube Loop of wire, snares, or suture material Sheath (to cover an object with spikes)

59 Specific Tools of your Arse-nal: Heavy Equipment Proctoscope/Sigmoidoscope/Colonoscope Important to check post removal for evidence of trauma/perforation: mucosal lacerations, bleeding, perforations, or missed foreign body Obstetric Vacuum Devices

60 Parks Rectal Retractor

61 Special considerations – Round, Firm Rounds objects – orange, tennis ball, cue ball Vacuum extractor or Simpsons obstetrical forceps Sponge or towel forceps Vibrators/dildos – towel clamps Organic material

62 Special considerations - Glass/Sharp Objects Sharp objects – surgery or GI Glass consider x-ray prior to DRE risk of breaking? glass jar with opening towards anus - fill with plaster of Paris (Toomey syringe) & set with NG or retractor in place *** exothermic effect Rubber-tipped forceps

63 Suction Effect FB that obstruct entire lumen may create negative pressure zone proximal to object Overcome by insertion of venting device (foley catheter, endotracheal tube, Blakemore tube) Foley catheter with balloon inflated beyond or within FB can then be used to apply traction

64 Special considerations - Overcome the vacuum

65 Innovative Removal Techniques

66 Ingenious Removal Methods 27 y/o male, inserted light bulb into his rectum, screw end of the bulb facing Removal technique: light socket attached to end of a broom handle Socket screwed onto the bulb, then evacuated Benjamin HB et al. Removal of Exotic Foreign Objects from the Abdominal Orifices ;6:

67 Ingenious Removal Methods 54 y/o male, 2 days previously drinking whiskey, did something to his rectum Later admitted he accepted a wager of $100 and used shaving cream as a lubricant Difficulty defecating and urinating Rectal exam: hard, smooth globular mass Removal technique: toy darts with suction cups used to draw electric bulb to sphincter; surface of exposed glass dried with ethyl ether swabs, then attempted to attach suction cup again with cyanoacrylate cement; eventually removed with 3 # 24 foley catheters Diwan VS et al. Removal of 100 Watt Electric Bulb from Rectum. Ann Emerg Med ;11:

68 Ingenious Removal Methods 28 y/o female, misadventure with boyfriend Vibrator lost in rectum, boyfriend tried to retrieve with salad tongs, which became lost as well Removal technique: laparoscopy used to push the rectal foreign body from above while it was reoved transanally from below Personal communication with Dr. E. Debru and Dr. I. Walker

69 Ingenious Removal Methods Petanque Boule: shiny metallic sphere 7.5 cm in diameter and 750 grams Boule palpable at fingertip, resting at rectosigmoid junction Bronson EM 301 electromagnet attached to 15 cm probe, delivered to anus, then shorter 3 cm probe attached Coulson CJ et al. Extraction of rectal foreign body using an electromagnet. Int J Colorectal Dis (2005) 20:

70 Petanque Balls

71 Ingenious Removal Methods 44 y/o male, introduced a large cellophane- covered green apple into the rectum 24 hours prior to admission Surface of the solid foreign body treated with an argon beam coagulator, melting down the apple continuously After 2.5 hours, apple melted down to less than 50% its original size, remainder removed with foreign body forceps Glaser J et al. Unusual Rectal Foreign Body: Treatment Using Argon- Beam Coagulation. Endoscopy 1997; 29:

72 Apple Crisp

73 Unusual Rectal Foreign Bodies from the Top Down

74 Unusual Rectal Foreign Bodies: From the Top Down Ingested Foreign bodies accidentally or intentionally can result in rectal FBs, obstruction and perforation Risk factors: small children patients with altered LOC (alcohol or drug use), dementia, consumption of high risk foods (chicken or fish bones), illicit activities (drug smuggling), structural abnormalities of GI tract (marble, ulcerative colitis and rectal stricture) Bloom R et al. Foreign Bodies in the gastrointestinal tract. Am Surg 1986;52(11):

75 Unusual Rectal Foreign Bodies: From the Top Down Fish and chicken bones Toothpicks Pessaries IUD VP shunt catheters Angiographic catheters (hepatic artery) Migrated esophageal Souttars stent Migrated colonic stents Sunflower seed rectal bezoar, fruit and vegetable bezoars Body packers, Body stuffers Case report: Spontaneous transanal bullet discharge following pelvic gunshot injury gives new meaning to the phrase shitting bullets

76 Complications

77 Traumatic disruption of sphincteric complex Intramural rectal hematoma (may present with obstructive symptoms) Case report: mucosal burns from leaking vibrator batteries Bowel obstruction Urinary retention Perforation of bowel wall Pelvic abcesses, perivesicular abcess, pelvic cellulitis, Fourniers gangrene, septic shock Case report: 2 y/o male, rectal thermometer broke, small perforation in posterior rectal wall, migrated into epidural space Case report: 5 y/o male, rectal thermometer broke, fragments retrieved, 6 months later presented with dysuria, hematuria, and passed a few drops of mercury in urine, transvesicular migration Extreme embarrassment

78 Complications Case report: 58 y/o male, confusion, inability to speak, PMhx: rectosigmoid plastic soda bottle extraction 2 years previously Febrile, tachycardic, hypotensive Apical pansystolic murmur, mixed receptive and expressive aphasia, right hemiparesis, perianal erthyma, diminished sphincter tone MRI: infarction of occipital and frontal lobes TEE: vegetations of mitral valve Blood cultures: MSSA Treatment: nafcillin and gentamycin Hypothesis: frequent colonization of rectum by S. Aureus, trauma to mucosa with secondary bacteremia and endocarditis Pandey BB et al. Embolic stroke complicating S.Aureus Endocarditis circumstantially linked to rectal trauma from foreign body: a first case report. BMC Infectious Diseases 2005,5:42

79 Rectosigmoid injuries Rectal Organ Injury Scale of the American Association for the Surgery of Trauma The American Association for the Surgery of Trauma has proposed a Rectal Organ Injury Scale: Grade I Hematoma: Contusion or hematoma without devascularization Laceration: Partial-thickness Grade II Laceration 50 percent circumference Grade III Laceration >50 percent circumference Grade IV Full-thickness laceration with extension into the perineum Grade V Devascularized segment Moore EE et al. Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma Nov;30(11):1427-9

80 Rectosigmoid injuries Full thickness injuries rare, if occur 60% due to FB insertion, 30% fist fornication, 10% due to penile intercourse Perforations above peritoneal reflection: pneumoperitoneum, signs of peritonitis Perforations below: water soluble contrast enema or sigmoidoscopy, may have delayed presentation Perforation not limited to sharp objects but rather to the force of introduction No prediction models for duration of time rectal FB remain in situ to perforation; case reports of clinical presentation of perforation 72 hours post removal Barone JE et al. Perforation and foreign bodies of the rectum, report of 28 cases. Ann Surg 1976;184:

81 Surgical Management: Dictated by degree of injury and fecal contamination Small clean wound with clean edges: primary repair Gross fecal contamination: abdominal irrigation with repair or resection of injured colon and proximal end sigmoid colostomy, with mucous fistula or Hartmanns procedure treatment of choice Barone JE et al. Management of Foreign Bodies of Trauma of the Rectum. Surgery Gynecology & Obstetrics /4:

82 Post Extraction Management Sigmoidoscopy Observation and repeat examinations Discharge Instructions Avoid repeated trauma: Never do that again Fever Increasing abdominal pain Urinary retention

83 Dispostion: Outpatient versus Inpatient management Controversy exists regarding outpatient versus inpatient observation management of patients with rectosigmoid lacerations Largest review of rectosigmoid lacerations caused exclusively by anorectal eroticism supports discharge of patients with minor lacerations after thorough ED work-up Hicks TC, Opelka FG. The hazards of anal sexual eroticism. Persp Colon Rectal Surg 1994;7:37-57

84 Long-term complications Data extraction from prospective computerized data base April 1989-April 1997, Singapore General Hospital 30 patients (25 men, 5 women) Standardized management protocol Clinical features, results analysed: 12: transanal recovery with sedation General anesthesia in 13 Laparotomy in 3 Long-term follow-up by telephone interview at 63 months follow-up, in addition to hospital and public hospital medical records review No long-term complications of faecal incontinence or re-impaction of FB Boon-Swee Ooi et al. Management of Anorectal Foreign Bodies: A Cause of Obscure Anal Pain. Aust.N.Z.J. Surg.(1998)68,

85 Legal Ramifications

86 Pediatrics Child abuse or deviant sexual activity account for most rectal injuries in children; Exception: straddle injuries No FB in this series Only 2 Case reports in literature: 14 y/o male with empty soda can in rectum, 14 y/o male with vibrator in rectum Case report: chewing gum bezoars of GI tract; 4 ½ year old boy and girl, swallowed 5-7 pieces of gum/day, presented with constipation and encopresis Black CT et al. Ano-rectal Trauma in children. Journal of Pediatric Surgery 1982;17(5): 501-4

87 Legal Ramifications: Drug Mules Involvement of practitioner with patients who conceal illicit drugs within their rectums automatically entails legal responsibility 2 circumstances: patient in custody of legal authorities, patient comes in on own Unstable: treat High risk of container rupture following instrumentation of any kind Stable: If patient refuses consent, cannot remove anything. Considered as assault. Stable: Can send to lab as FB removal for identification; medical indication in the event symptoms develop; on independent investigation, police can then can subpoena results from hospital laboratory Warrant does not permit you to talk to legal authorities or conduct FB removal Discussion with CMPA January 15 th 2009 Dr. Wayne Helmer

88 Drug Mule

89 Legal Ramifications: Assault Treat as any other sexual assault Activate CSART for collection and preservation of evidence Ideally swabbing with gauze (ideally forensic swab, sterile swab without media)

90 Guess What I am?

91 Image 1: Where is the ring?

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109 Epoxy Case Details Case: 27 y/o male, presented with lower abdominal discomfort 5 hours post injection of a liquid adhesive (epoxyacrylate resin) into his rectum with a dual-chambered glue gun Instantaneous exothermic reaction caused mixture to solidify and become fixed internally Similar case with concrete

110 Image 11: Epoxy Cast of Rectum

111 Conclusions High index of suspicion in non-specific abdominal pain in the setting of inconsistent history and physical findings Consider ED removal in selected cases of low-lying foreign bodies under direct visualization Consider post-removal sigmoidoscopy/colonoscopy, duration of post-removal observation unclear Risk of perforation higher correlation to force of introduction than to type of foreign body Serious morbidity and mortality Insert at your own risk


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