Presentation on theme: "Rectal Foreign Bodies and Other “Weapons of Ass Destruction” II: Return of the Red Eye Good evening. St Paul’s is probably the unofficial center of excellence."— Presentation transcript:
1Rectal Foreign Bodies and Other “Weapons of Ass Destruction” II: Return of the Red Eye Good evening. St Paul’s is probably the unofficial center of excellence for rectal FB and this topic is not one that is not taught in medical school or residency and finally we have personally found dealing with these cases difficult and unpleasant so we ultimately decided that this topic was worth discussing for more a good laugh.Michael Su MD CCFP(EM)Emergency Medicine Grand Rounds January 29th, 2009
2Accreditations/special thanks to: Dr. Eric Grafstein, MD,FRCPDr. Rick Walker, MD FRCPMs. Monica Fredborg, RTR
3The following hairstyle is associated with: A) rectal foreign bodiesB) aC) a + bD) all of the abovePlease have slide effect here
4Objectives Review Epidemiology of Foreign Bodies Structural Issues History and physical examReview ManagementIssues Around RemovalSpecial casesComplicationsLegal implicationsSkill-testing session: “What am I”I will review that epidemiology of rectal FB and then initiate the discussion on the management and Eric will concentrate on issues surrounding the removal of the FB in the ED..
5Case 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 I’d 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 didn’t teach you about this in medical school, and that you believe there is still time to reassign the patient to Dr. Abbi on REDIS…So consider the following case…picture of GAVIN, slide againWonder… could you have prevented need for the OR; what could you have doen differently. And finally… why did he have to show up on your shift in the first place. Nevertheless, he has and now we want to discuus some issues surrounding the removal of FB…
6Search Methodology Medline 1966 - current Wolters Kluwer | OvidSP Aside: I did this search at the library, as you may or may not now, I’m quite technically inept and I recruited a libarian to help with the search. I’ve never encountered a loud librarian until that dayI may be of a person of interest for the Calgary Police Forces Sexual Deviancy Squad
7Results of search 240 articles found 175 identified as possibly relevantAbstracts reviewed (large number of case studies, no RCT identified)bibliographiesExpert consultation with ….Slid
8Google search “weapons of ass destruction” items retrieved in 0.2 secondsDr. Collin’s recommended running another search engine against weapons of ass destruction and ………………..
10Incidence and prevalence Mostly case series, with ranges of 8 to 101 cases on average over 5 year periods,Calgary data, St. Paul’s datamale predominate 35:1? Bimodal distribution (30’s and 60’s) although all ages included, all data based on very small sample sizesIncidence is increasingPresentation: typically 6-48 hours after transanal insertion; 48 hours-3 months after orally ingested rectal FBSingaporewella 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:Change reference font
11Incidence and prevalence UpToDate Online 16.3, 2009
12Maybe we should ask the registrants at this conference… Hopefully this was picked up after the picture was taken but the sign states…There are no good stats in the literature about the actual numbers but several articles noted that the incidence appears to be increasing. At least it is being reported more often.
13Calgary Health Region 2003-2008 These are the stats for St Paul’s. The numbers at St. Paul’s since involve about 28 patients roughly 6-7 per year and approximately half of these ended up being admitted. It is not clear what the reasons for admission were.
14Rectal Foreign Bodies at SPH These are the stats for St Paul’s. The numbers at St. Paul’s since involve about 28 patients roughly 6-7 per year and approximately half of these ended up being admitted. It is not clear what the reasons for admission were.
16Anatomy Netter, Atlas of Human Anatomy, 1989 Anal canal 4 cm long, rectum 12 cm long beginning at 3rd sacral vertebraRectum covered with peritoneum for first two-thirds of its courseArterial and venous supply of rectum: superior, middle, and inferior hemorrhoidal arteries and veinsLymphatics: inguinal lymph nodes, external iliac or common iliac lymph nodesAnal canal lined by stratified epithelium, highly sensitive to pain; rectum lined by mucosa, insensitive to painOnce above levator ani, muscles and conical shape of the pelvis cause the FB to rise above the pelvic brim; FB usually becomes impacted at the sacral hollow where rectum forms a sharp anteriorposterior curve
18Anatomical Considerations Anal canal 4 cm long, rectum 12 cm long beginning at 3rd sacral vertebraRectum covered with peritoneum for first two-thirds of its courseArterial and venous supply of rectum: superior, middle, and inferior hemorrhoidal arteries and veinsLymphatics: inguinal lymph nodes, external iliac or common iliac lymph nodesAnal canal lined by stratified epithelium, highly sensitive to pain; rectum lined by mucosa, insensitive to painOnce above levator ani, muscles and conical shape of the pelvis cause FB’s to rise above the pelvic brim; FB usually becomes impacted at the sacral hollow where rectum forms a sharp anteriorposterior curveIrizarry 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
19Physiological Considerations 4 groups of muscles involved in anorectal physiology:1. external sphincter: striated muscle, voluntary control, prevents defecation even when urge present2. internal sphincter: prevents stool from entering anus, maintains stool in rectum causing rectal ampulla to dilate3. puborectalis: reflexively intitiates defecation in a propulsive wave, provided external sphincter relaxed4. levator ani: finishes expulsion of stoolBrenner BE, Simon RR: Anorectal emergencies. Ann Emerg Med 12: , June 1983
20Circumstances of Rectal Foreign Body Introduction 1. diagnostic or therapeutic: thermometer, barium, rectal tube, disposable enema tip, irrigation catheters2. self-administered treatment to alleviate symptoms of anorectal disease eg. Insertion of broomstick to relieve itching or to reduce prolapsed hemorrhoids3. criminal assault4. autoeroticism5. accidental introductionEftaiha M et al: Principles of Management of Colorectal Foreign Bodies. Arch Surg 112: ,1977
22ClassificationMany different characteristics (shape, composition, surface contour, orientation) influence ultimate method of removalInitial approach:1. low-lying: palpable in the rectal ampulla2. high-lying: in or proximal to the rectosigmoid junction
23Classification 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 World’s Literature. Surgery 1986; 100(3):
24Classes of Foreign Bodies Glass or ceramicBottle or jarBottle with attached ropeGlass or cupLight bulbTubeFoodAppleBananaCarrotCucumberOnionParsnipPlantain (with condom)PotatoeSalamiTurnipZucchiniWoodenAxe handleStick or broom handleMiscellaneousKitchen DevicesDull knifeIce pickKnife sharpenerMortar & pestleSpatula (plastic)SpoonTin cupMisc toolsCandleFlashlightIron rodPenRubber tubeScrewdriverToothbrushWire springInflated deviceBalloonBalloon attached to cylCondomBicycle inner tubeBallsBaseballTennis ballBocce ballMisc ContainersCandleboxSnuffboxBaby powder canOrganized by food groupfruits & vegBusch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the World’s Literature. Surgery 1986; 100(3): 512-9
25...Miscellaneous Bottle cap Cattle horn Frozen pigs tail Kangaroo tumorPlastic rodStoneToothbrush holderToothbrush packageWhip handleGerbilBusch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the World’s Literature. Surgery 1986; 100(3): 512-9
26...Collections 2 glass tubes 72-1/2 Jeweller’s saw Oil can with potatoe stopperPiece of wood, and peanutUmbrella handle and enema tubing2 GlassesPhosphorous match ends (homicide)402 stonesToolbox2 bars soapBeer glass and preserving potLemon and cold cream jar2 applesspectacles, suitcase key, tobacco pouch, magazineBusch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the World’s Literature. Surgery 1986; 100(3):
27Age DistributionNOTE the Retirement Stimulus PackageBusch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the World’s Literature. Surgery 1986; 100(3): 512-9
29World Records 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):286-7Staged bullets, slant reference
30World Records 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 cmRemoved with bone forcepsSachdev YV et al. An Unusual Foreign Body in the Rectum. Diseases of the Colon and Rectum ;3:
31World Records What is the best travelled rectal FB on record? Case Report:bachelor, mid 60’s presented with severe anal pain after vigorous extracurricular activities the night before.Freely mobile palpable abdominal mass, painful rectal examReferred for surgical opinion, declined as patient stated he was on a world tourReturned 6 months later for FB removal, 20 cm x 2.5 cm vibrator removedLongest recorded in situ FB case recordedAlso best travelledBuzzard AJ et al. A Long-Standing, Much Travelled Rectal Foreign Body. Med.J. Aust., 1979, 1:600Papillon, Henry Charriere, and his charger: 3 ½ inch aluminum tube, thumb thick
33Management of Rectal Foreign Bodies So the Approach to rectal FB. I will first discuss an overall approach/view from the top OR SHOULD I SAY VIEW FROM THE BOTTOM, and then I discuss specific issues around component of the approachSingaporewella 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:
34History “How did it happen” Description of the circumstances surrounding the injury is usually suspiciousUsually attributed to some type of accident or therapeutic misadventure~1/3 admit to transanal insertion, 2/3 complain of vague anal painAlways be attuned to the possibility of physical abuseBoon-Swee Ooi et al. Management of Anorectal Foreign Bodies: A Cause of Obscure Anal Pain. Aust.N.Z.J. Surg.(1998)68,Sequential bullets
35History 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 rectumHe 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 rectum57 y/o male, massaging his “rear end” with a jar of petroleum jelly to relieve a bothersome itchHe “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 bedMcDonald PT et al. An Unusual Foreign Body in the Rectum-A Baseball: Report of a Case. Dis Colon Rectum 1977; 20:1 56-7Be prepared for fantastic stories when you ask how did it happen, then staged bullets
36History: 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 painRectal FB risk factor on hx: admitted for urethral FB extraction 2 years previouslyEventual hx came out, FB removed in OR under spinal48 hours, intra-abdominal sepsis, peritonitisPerforated sigmoid colon, Hartmann’s procedure, discharged 6 weeks laterDale OT et al. Tube abuse: a rectal foreign body presenting as chest pain. ANZ Journal of Surgery 2007; 77(12):1131-2I have case here for Dr. Gianocorro, because this patient could have easily been admitted to his service
37History: 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
38Physical ExamFocus on abdomen (to exclude perforation),inspection of anus, and careful digital examUnusual avoidance of pelvic/anal examsRectal/vaginal lacerations, bleeding, scarsAnal fissures, fistulasMucosal irritation (secondary to soaps, shampoos used as lubricants)Foul-smelling anal or vaginal dischargeLocalized discomfort to anus, vaginaThe “vibrating umbilicus” sign (Mike Betzner)25 y/o male, loss of vibrator, deep central abdominal ache, vibrating umbilicus, and a gentle humAttempt to deliver the vibrator too painful but manipulation resulted in mechanism being turned off, with resolution of pain and vibrationsJackson D et al. Vibrating Umbilicus. BMJ. 2/Anoop Manocha has told me that he is able to differentiate between the Lincoln Mark 4 and Mark 5 Anal anialator just by palpating the frequency of vibrations on a patient’s abdomen
40Investigations: ECGA middle-aged man presented with a buzzing sound audible on auscultationQuestions: what is the PR interval? What is the dysrhythmia?Hammond EJ et al., An Unusual ECG. Anaesthesia, 2001, 56(4):402.
42Role of Imaging Define the foreign body Free air? Is there only one? Timing?To provide content for emergency medicine grand roundsPlain radiography has a role in the approach to this condition. It can better define the location and the shape of the object and perhaps whether there is a risk to you or the patient if you try and remove it – sharp objects placed in the rectums of prisoners and psychiatric patients may actually be placed there to cause harm.IIf you are not convinced there are peritoneal signs but the patient is in a lot of pain then an x-ray demonstrating free air would be useful.Again in the unreliable patient either because of psychiatric or criminal issues, it may be prudent to document that there is in fact only one FB before you send them back to jail or off to psychiatry.When exactly do you do the x-ray is an issue. I do not routinely do an x-ray on all patients. If I have clear history I will simply proceed to do a digital rectal exam without first doing an x-ray.This is an imaging modality whose time has come. These specially trained kamakazee mice when inserted in the rectum.
43Radiographic Detection of Foreign Bodies Classification1. highly radiopaque: high physical density, low photographic density on radiograph (bullet fragments, surgical clips, orthopedic hardware2. 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 examinedDenser material absorbs more photonsFodor J et al. The Radiographic Detection of Foreign Bodies. Radiological Technology /5:361-70How hard is it to spot foreign bodies on plain radiographs, now that all depends …….
44Radiolucent Foreign Body Objects Lee KF et al. Radioluscent foreign body visible on plain radiography. Can J Surg ;3:
45Radiolucent Foreign Body Objects Lee KF et al. Radioluscent foreign body visible on plain radiography. Can J Surg ;3: 87-88
46Radiographic Detection of Foreign Bodies Misconceptions: glass, aluminum, woodGlass: all glass normally encountered radiopaque compared to body tissueAluminum: metal of low physical density, may be very difficult to detect radiographicallyWood: dry wood lower physical density than body tissues, within hours becomes water logged and equivalent in density to body tissueFodor J et al. The Radiographic Detection of Foreign Bodies. Radiological Technology /5:361-70
47Radiographic Detection of Foreign Bodies Contrast studies: foreign bodies present as filling defects in the contrast-filled structure. gastrograffin enemaComputed Tomography: can detect differences in tissue density as low as 0.5%Ultrasound
49ED Principles of Removal Exclude perforationObject must be able to be removed transanallyHigh-lying bodies must be convertible to low-lying bodiesPlanned approach to removal; equipment for position conversion and extraction at bedsideNo ED removal if FB fragile and there is risk of bowel damage if it fragmentsWigle RL. Emergency Department Management of Retained Rectal Foreign Bodies. Am J Emerg Med 1988;6:
50ED Principles of Removal Minimize cross-sectional are of removal deviceSimple is better: most successful FB removed with some type of snare, encasing forcep, or piercing tenaculumRemove under direct visionOvercome the suction effectLimit time: no more than 30 minutesWigle RL. Emergency Department Management of Retained Rectal Foreign Bodies. Am J Emerg Med 1988;6:
51The Difficulty with Removing Rectal FB FB usually has a smooth surface, difficult to graspOften very friable (e.g. vegetable) or very hard (glass)Mucous/blood make traction and visualization difficultAnal sphincter may be is spasm or oedematousRectal mucosa may be oedematous or bulgingCurve of sacrum tends to hold the lower end of the FB away from the anusBlunt end of the FB usually presents caudallyHigh-lying objects sometimes trapped either by rectosigmoid junction or the iliac spinesNegative pressure may develop above the FB when traction is attempted, creating a suction effect on the FBCouch CJ et al. Rectal FB. Med J Aust 1986;144:
52Palpable Rectal Foreign Bodies Trial of removalSuccessfulUnsuccessfulPost extraction managementAnd finally removal of the palpable FB. I attempt this without any sedation initially and am either successful or need to proceed to a conscious sedationReferral to General Surgery
53Removal of the Palpable Foreign Body There are several factors working against us. The presence of sphincter spasm, the shape of the object, the creation of a vacuum behind the object and the anatomy.In terms of the anatomy the FB can become held up by the sacrum and coccyx so it is useful to try and bring the FB anterior as you move it down.
54Removal of the Palpable Foreign Body Local anesthetic written about but not usedSedate the patient well (propofol)Relax patientRelax anal sphincterLithotomy position: helps to ease the passive tension of the abdominal wall muscles; heads up position assists with gravityGet 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
55Abdominal Pressure or Valsalva Maneuver In terms of abdominal manipulation, the patient is in the lithotomy position and with one hand in the rectum you can either do this with your other hand or get someone else to do it. There are no reports of causing harm with this but gentle pressure should be used. If the patient is able to cooperate then you can try to get them to do a valsalva maneuver but remember to stand off to the side when you are doing this or you may get a nasty surprise.
57Specific Tools of your “Arse-nal” Digital removalParks retractors, vaginal speculumTenaculum/Ringed ForcepsLabour and Delivery ForcepsFoley catheters, endotracheal tubes, Sengstaken-Blakemore tubeLoop of wire, snares, or suture materialSheath (to cover an object with spikes)
58Specific Tools of your “Arse-nal”: Heavy Equipment Proctoscope/Sigmoidoscope/ColonoscopeImportant to check post removal for evidence of trauma/perforation: mucosal lacerations, bleeding, perforations, or missed foreign bodyObstetric Vacuum Devices
60Special considerations – Round, Firm Rounds objects – orange, tennis ball, cue ballVacuum extractor or Simpson’s obstetrical forcepsSponge or towel forcepsVibrators/dildos – towel clampsOrganic material
61Special considerations - Glass/Sharp Objects Sharp objects – surgery or GIGlassconsider x-ray prior to DRErisk of breaking?glass jar with opening towards anus - fill with plaster of Paris (Toomey syringe) & set with NG or retractor in place *** exothermic effectRubber-tipped forceps
62Suction EffectFB that obstruct entire lumen may create negative pressure zone proximal to objectOvercome 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 tractionFor anyone here who’s tried to take one of these out, it is often feels like someone is pulling in the opposite direction as you are
64Innovative Removal Techniques The only thing more original than the foreign bodies themselves very well may be the removal techniques
65Ingenious Removal Methods 27 y/o male, inserted light bulb into his rectum, screw end of the bulb facingRemoval technique: light socket attached to end of a broom handleSocket screwed onto the bulb, then evacuatedBenjamin HB et al. Removal of Exotic Foreign Objects from the Abdominal Orifices ;6:
66Ingenious Removal Methods 54 y/o male, 2 days previously drinking whiskey, “did something” to his rectumLater admitted he accepted a wager of $100 and used shaving cream as a lubricantDifficulty defecating and urinatingRectal exam: hard, smooth globular massRemoval 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 cathetersDiwan VS et al. Removal of 100 Watt Electric Bulb from Rectum. Ann Emerg Med ;11:“I think I could come up with an easier way to make a 100 bucks”
67Ingenious Removal Methods 28 y/o female, misadventure with boyfriendVibrator lost in rectum, boyfriend tried to retrieve with salad tongs, which became lost as wellRemoval technique: laparoscopy used to push the rectal foreign body from above while it was reoved transanally from belowPersonal communication with Dr. E. Debru and Dr. I. Walker
68Ingenious Removal Methods Petanque Boule: shiny metallic sphere 7.5 cm in diameter and 750 gramsBoule palpable at fingertip, resting at rectosigmoid junctionBronson EM 301 electromagnet attached to 15 cm probe, delivered to anus, then shorter 3 cm probe attachedCoulson CJ et al. Extraction of rectal foreign body using an electromagnet. Int J Colorectal Dis (2005) 20:Petanque balls are the french equivalents of Bocce balls
70Ingenious Removal Methods 44 y/o male, introduced a large cellophane-covered green apple into the rectum 24 hours prior to admissionSurface of the solid foreign body treated with an argon beam coagulator, melting down the apple continuouslyAfter 2.5 hours, apple melted down to less than 50% its original size, remainder removed with foreign body forcepsGlaser J et al. Unusual Rectal Foreign Body: Treatment Using Argon- Beam Coagulation. Endoscopy 1997; 29:“I guess you could call this a new way of making Apple Crisp”
73Unusual Rectal Foreign Bodies: “From the Top Down” Ingested Foreign bodies accidentally or intentionally can result in rectal FB’s, obstruction and perforationRisk factors:small childrenpatients 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):Marble case: FB removed with explosive results
74Unusual Rectal Foreign Bodies: “From the Top Down” Fish and chicken bonesToothpicksPessariesIUDVP shunt cathetersAngiographic catheters (hepatic artery)Migrated esophageal Souttar’s stentMigrated colonic stentsSunflower seed rectal bezoar, fruit and vegetable bezoarsBody packers, Body stuffersCase report: Spontaneous transanal bullet discharge following pelvic gunshot injury “gives new meaning to the phrase shitting bullets”
76ComplicationsTraumatic disruption of sphincteric complexIntramural rectal hematoma (may present with obstructive symptoms)Case report: mucosal burns from leaking vibrator batteriesBowel obstructionUrinary retentionPerforation of bowel wallPelvic abcesses, perivesicular abcess, pelvic cellulitis, Fournier’s gangrene, septic shockCase report: 2 y/o male, rectal thermometer broke, small perforation in posterior rectal wall, migrated into epidural spaceCase 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 migrationExtreme embarrassment
77Complications Case report: 58 y/o male, confusion, inability to speak, PMhx: rectosigmoid plastic soda bottle extraction 2 years previouslyFebrile, tachycardic, hypotensiveApical pansystolic murmur, mixed receptive and expressive aphasia, right hemiparesis, perianal erthyma, diminished sphincter toneMRI: infarction of occipital and frontal lobesTEE: vegetations of mitral valveBlood cultures: MSSATreatment: nafcillin and gentamycinHypothesis: frequent colonization of rectum by S. Aureus, trauma to mucosa with secondary bacteremia and endocarditisPandey 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
78Rectosigmoid injuries Rectal Organ Injury Scale of the American Association for the Surgery of TraumaThe American Association for the Surgery of Trauma has proposed a Rectal Organ Injury Scale:Grade I — Hematoma: Contusion or hematoma without devascularization Laceration: Partial-thicknessGrade II — Laceration ≤50 percent circumferenceGrade III — Laceration >50 percent circumferenceGrade IV — Full-thickness laceration with extension into the perineumGrade V — Devascularized segmentMoore EE et al. Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma Nov;30(11):1427-9
79Rectosigmoid injuries Full thickness injuries rare, if occur 60% due to FB insertion, 30% fist fornication, 10% due to penile intercoursePerforations above peritoneal reflection: pneumoperitoneum, signs of peritonitisPerforations below: water soluble contrast enema or sigmoidoscopy, may have delayed presentationPerforation not limited to sharp objects but rather to the force of introductionNo prediction models for duration of time rectal FB remain in situ to perforation; case reports of clinical presentation of perforation 72 hours post removalBarone JE et al. Perforation and foreign bodies of the rectum, report of 28 cases. Ann Surg 1976;184:
80Surgical Management:Dictated by degree of injury and fecal contaminationSmall clean wound with clean edges: primary repairGross fecal contamination: abdominal irrigation with repair or resection of injured colon and proximal end sigmoid colostomy, with mucous fistula or Hartmann’s procedure treatment of choiceBarone JE et al. Management of Foreign Bodies of Trauma of the Rectum. Surgery Gynecology & Obstetrics /4:
81Post Extraction Management SigmoidoscopyObservation and repeat examinationsDischarge InstructionsAvoid repeated trauma: “Never do that again”FeverIncreasing abdominal painUrinary retention
82Dispostion: Outpatient versus Inpatient management Controversy exists regarding outpatient versus inpatient observation management of patients with rectosigmoid lacerationsLargest review of rectosigmoid lacerations caused exclusively by anorectal eroticism supports discharge of patients with minor lacerations after thorough ED work-upHicks TC, Opelka FG. The hazards of anal sexual eroticism. Persp Colon Rectal Surg 1994;7:37-57
83Long-term complications Data extraction from prospective computerized data base April April 1997, Singapore General Hospital30 patients (25 men, 5 women)Standardized management protocolClinical features, results analysed:12: transanal recovery with sedationGeneral anesthesia in 13Laparotomy in 3Long-term follow-up by telephone interview at 63 months follow-up, in addition to hospital and public hospital medical records reviewNo long-term complications of faecal incontinence or re-impaction of FBBoon-Swee Ooi et al. Management of Anorectal Foreign Bodies: A Cause of Obscure Anal Pain. Aust.N.Z.J. Surg.(1998)68,
85PediatricsChild abuse or deviant sexual activity account for most rectal injuries in children; Exception: straddle injuriesNo FB in this seriesOnly 2 Case reports in literature: 14 y/o male with empty soda can in rectum, 14 y/o male with vibrator in rectumCase 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 encopresisBlack CT et al. Ano-rectal Trauma in children. Journal of Pediatric Surgery 1982;17(5): 501-4
86Legal Ramifications: Drug Mules Involvement of practitioner with patients who conceal illicit drugs within their rectums automatically entails legal responsibility2 circumstances: patient in custody of legal authorities, patient comes in on ownUnstable: treatHigh risk of container rupture following instrumentation of any kindStable: 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 laboratoryWarrant does not permit you to talk to legal authorities or conduct FB removalDiscussion with CMPA January 15th 2009 Dr. Wayne Helmer
88Legal Ramifications: Assault Treat as any other sexual assaultActivate CSART for collection and preservation of evidenceIdeally swabbing with gauze (ideally forensic swab, sterile swab without media)
95Image 5: Any one have any bright ideas? Halogen/neon filled? Light bulb wattage; is this light bulb energy efficientMost are for auto eroticism but others defy a rational explanation. If you happen to work near a prison or in an area with a lot of psychiatric patients then you may be faced with this problem.Some objects will be easier to remove than others but the question is whether to attempt removal in the ED or simply to refer onto surgery and let them try in the OR where the patient becomes much more compliant with a little succinylcholine. Certainly, any patient with signs of peritonitis needs the OR, any object that is at risk of breaking is best taken out in the OR as are objects that are likely to cut or puncture you or the patient then it is best to use the more controlled environment of the OR..Finally, it is important to consider abuse in these cases. IT si reported and patients can be reluctant to admit to abuse at the best of times but add to it the embarrassment of having a FB up your bum and this issue can be easily missed.
96Image 6:The requisition states rule out foreign body rectum. No metallic foreign bodies are identified. There is however a rather homogeneous elongate soft tissue density foreign body roughly the size of a cucumber approximately 26 cm in length superimposing the expected course of the sigmoid colon. Definite correlation with the clinical history is required. The bowel gas pattern is otherwise unremarkable. No other specific abnormality is identified.
97Image 7:Arrows point to radiolucent stripes referred to as the "double condom sign", formed by air trapped between two layers of latex.This double condom size is not to be confused with the double condom sign seen in couples who really really don’t want to get pregnant
98Image 8:This person took the Pepsi taste challenge
102Image 12:Ah barbasol, the king of lathers, may be a more appropriate logo should be be ass-buster
103Image 13: What kind of jar (peanut butter) What brand : Skippy Smooth or crunchy?Any peanut allergies?Most are for auto eroticism but others defy a rational explanation. If you happen to work near a prison or in an area with a lot of psychiatric patients then you may be faced with this problem.Some objects will be easier to remove than others but the question is whether to attempt removal in the ED or simply to refer onto surgery and let them try in the OR where the patient becomes much more compliant with a little succinylcholine. Certainly, any patient with signs of peritonitis needs the OR, any object that is at risk of breaking is best taken out in the OR as are objects that are likely to cut or puncture you or the patient then it is best to use the more controlled environment of the OR..Finally, it is important to consider abuse in these cases. IT si reported and patients can be reluctant to admit to abuse at the best of times but add to it the embarrassment of having a FB up your bum and this issue can be easily missed.
108Epoxy Case DetailsCase: 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 gunInstantaneous exothermic reaction caused mixture to solidify and become fixed internallySimilar case with concreteWhat is the technical term for injection of enemas for sexual gratification? Klismaphalia
110ConclusionsHigh index of suspicion in non-specific abdominal pain in the setting of inconsistent history and physical findingsConsider ED removal in selected cases of low-lying foreign bodies under direct visualizationConsider post-removal sigmoidoscopy/colonoscopy, duration of post-removal observation unclearRisk of perforation higher correlation to force of introduction than to type of foreign bodySerious morbidity and mortalityInsert at your own risk