1. Before the end…

2. The End. Or, Rectal Foreign Bodies Melissa Ying R2 Dec 15 2006

3. Objectives Develop a systematic approach to rectal and sigmoid foreign bodies Identify potential sources of foreign bodies and their significance Classify rectal foreign bodies in a manner relevant to their management Review current literature

4. History of RFB First documented in 16 th century Few studies conducted until the 1970s onwards.

6. Systematic Approach Presentation Etiology Differential Diagnostic Aids Management Potential Complications

7. Presentation Confession Pain in rectum/Local discomfort Obstruction Perforation Sepsis or Toxic Shock Toxicity Incidental

8. Etiology Ingested Inserted (transanally) Autoerotic Concealment Accidental Assault Iatrogenic Transmural

9. Iatrogenic, transmural Intraabdominal pacemaker in 2 yr old child Still functioning Caused failure to thrive. International Journal of Cardiology Volume 107, Issue 2International Journal of Cardiology Volume 107, Issue 2, 15 February 2006, Pages 287-288

10. Differential Diagnosis Tumour Feces Prolapse

11. Diagnosis depends on… History Abdominal exam Rectal exam Plain radiography

12. Classifications Benign vs. Malignant? Cystic vs. Solid? Sharp vs. Dull? Inert vs. Chemically active? Gas, liquid, solid? Animal, vegetable, mineral?

13. Cystic? 100 watt lightbulb Removed intact using Foley catheters and mineral oil Annals of Emergency Medicine November 1982

14. Solid? 30 cm wooden rod inserted transanally and retained for 1 month Removed transanally using rigid NG tube to introduce air proximally Journal of the American College of Surgeons Volume 203, Issue 1Journal of the American College of Surgeons Volume 203, Issue 1, July 2006, Pages 132-133

15. …or?? Epoxy resin injected by patient Presented with pain 5 hrs later Poison control contacted Rectal “cast” delivered by manipulation Journal of Gastrointestinal Surgery Journal of Gastrointestinal Surgery Volume 9, Issue 5, May-June 2005, Pages 747-749olume 9, Issue 5

16. Animal? …sorry, no story. Just pictures.

17. Potential Complications Sepsis Embolic stroke Perforation Toxicity Local injury (burns, tears) Missed assault

18. Management Resuscitate (if needed) Initial exam Simple removal? Plain radiograph Free air, object identification, localization Exam under Anaesthesia May need to overcome “vaccuum” phenomenon

19. Management Laparoscopy Lap assisted removal without enterotomy Enterotomy Laparotomy Likely enterotomy Repair of any perforation

20. Management Visualize rectosigmoid with sigmoidoscopy Should be managed by general or colorectal surgeon

21. Lap-assisted removal Insertion of “toothbrush case” for self-enema Dis Colon Rectum. 2005 Oct;48(10):1975-7

22. The packer: Most common drugs: cannabis products, heroin, cocaine “Packs” designed to be radiolucent May present with obstruction or toxicity

23. The packer: Eur Radiol (2004) 14:736–742

24. One study’s population… All 13 patients were male Age range 2–66 years. 7 Caucasian, 4 African and 1 Asian. The foreign bodies included: a penknife, an aerosol deodorant spray can, a blue plastic tumbler, a plastic bag containing two bank-notes and some marijuana, a plastic packet containing fish hooks, a penlight torch, a broomstick, a battery powered vibrator, a primus stove, a cap of an aerosol can, a piece of wire, a piece of hosepipe wrapped with wire and an iron bar. Colorectal Disease Volume 7 Issue 1 Page 98 - January 2005

25. One study’s population: Entered via; anal autoeroticism (3) concealment (2) attention seeking behaviour (3) accidental (1) assault (2) to alleviate constipation (2). Colorectal Disease Volume 7 Issue 1 Page 98 - January 2005

26. One study’s population: Plain radiographs accurately demonstrated the site of the foreign body in 8 patients. Extraction via Laparotomy (5) 2 patients with peritonitis 3 who required extraction by colotomy. Transanal extraction (7): 4 required general anaesthesia to facilitate extraction; 3 under conscious sedation in ER The remaining patient extracted the foreign body himself and presented to hospital with a rectal perforation. Colorectal Disease Volume 7 Issue 1 Page 98 - January 2005

27. Questions?? “I have no idea how that got there…”