Snookered

These presentations are potentially challenging for a number of reasons:

• patient factors —
  embarrassment, unreliable history, psychiatric illness
• possible sexual assault
• body packers require special consideration due to forensic issues and potential toxicity of package rupture
• potential harm to patient and staff if the object is dangerous, e.g. sharp objects
• procedural sedation and local/ regional anesthesia is usually required for attempted removal in the ED
• life threats are rare but possible, e.g. perforation

Patients need to be treated with the utmost sensitivity, no matter how strange and seemingly comical the situation is. Patients may have coexistent mental illness, may have been subjected to terrible assaults or may just have had an unfortunate mishap!

Our role is to help… not judge.

History

• type of foreign body
• delay since foreign body placement
• factors leading to the presence of the foreign body

1. sexual —
   autoerotic (most common type of rectal foreign body presentation)
   assault
2. non-sexual —
   body packing or stuffing of drugs
   psychiatric illness (present in about a third of cases)
   intellectual disability
   ingestion, e.g. toothpicks, bones, plastic objects
   iatrogenic, e.g. retained rectal thermometer

• previous extrication attempts
• previous foreign body presentations and treatments employed
• complications —
  pain, impaction, bowel obstruction, perforation, urinary retention, gastrointestinal hemorrhage, package rupture in body packers
• presence of other injuries if assault/ non-accidental injury suspected
• past medical history —
  comorbidities, previous surgery, medications, allergies
• social history

Examination

• assess for life threats —
  use an ABC approach and assess vital signs
  rule out perforation as a priority (suspect if  hypotension, tachycardia, peritonism and/or fever)
  look for evidence of gastrointestinal hemorrhage, package rupture in a body packer and life-threatening associated injuries if suspected assault
• abdominal examination —
  look for palpable mass, urinary retention, obstruction and perforation/ peritonism
  consider other causes of abdominal pain and perform genital examination
• rectal examination —
  assess for a palpable foreign body, for hemorrhage and for anal tone
  beware of potentially hazardous foreign bodies (e.g. sharp object)
• assess for associated injuries (head-to-toe exam)
• assess for toxidromes, e.g. heroin or cocaine toxicity in a body packer
• mental status examination

Laboratory tests are usually of limited utility in this setting

Bedside

• blood glucose and VBG: e.g. suspected obstruction or perforation, vomiting
• urine bHCG if female
• anoscopy, e.g. with small vaginal speculum

Laboratory

• FBC, UEC, LFTs, lipase: consider the differential diagnosis of abdominal pain
• Group and Hold: if significant hemorrhage

Imaging

• AXR and erect CXR: identify type and location of foreign body; stable patients with suspected complications such as obstruction or perforation
• CT abdomen: if body packing or foreign body is suspected but not visuallised on XR; stable patients with suspected complications such as obstruction or perforation

A circular radio-opaque object is present in the rectum. Complications cannot be excluded based on this image alone.

Immediate management

• manage ABCs; seek and treat life threats

Specific management

• consider removal of the foreign body in the ED if it is:

1. not a dangerous object
   (e.g. light bulbs have high risk of breakage)
2. palpable on PR exam
3. distal to the sigmoid on AXR
   (foreign bodies proximal to the sigmoid tend to abut the sacrum preventing removal)

• provide adequate analgesia and sedation —
  e.g. titrated morphine and midazolam
  Ideally ensure the patient remains awake enough to help ‘push’
• provide local/ regional anesthesia —
  Perform a perianal block, e.g. circumferential subcutaneous infiltration around the anus using lignocaine with adrenaline, followed by a deeper intersphincteric block.
  A pudendal nerve block can also be performed.
• attempt foreign body removal using a stepwise approach and set a 10-20 minute limit on the duration of  attempted removal in the ED —
  Position the patient, e.g. lithotomy position; alternatives include: lateral decubitus, prone, or knee-chest position
  First attempt removal by pushing on the abdomen to propel the foreign body distally while pulling on the object with the fingers of your other hand inside the patient’s rectum. Forceps or a clamp may also be used.
  If unsuccessful, consider passing a foley catheter past the foreign body to help break the suction around the object (air can be insufflated proximal to the foreign body via the foley). Then inflate the balloon and withdraw to help dislodge the object.
• if still unsuccessful, obtain a surgical consult and consider the following options:

1. patient repositioning
2. sigmoidoscopy
3. vacuum devices
4. per rectal removal under general anesthesia
5. use of obstetric forceps
6. endoscopy-assisted removal
7. laparoscopy-assisted removal
8. laparotomy

• seek and treat complications —
  e.g. perforation, obstruction, hemorrhage, urinary retention, anal tone/ sphincter dysfunction, toxicity from package rupture in body packers, and medication adverse reactions (e.g. allergy, effects of procedural sedation)
• aftercare —
  consider performing anoscopy/ sigmoidoscopy following removal of a rectal foreign body to check for evidence of trauma

Supportive care and monitoring

• may include —
  IV hydration, analgesia, sedation, IDC, NGT if obstruction
• psychosocial support
• consider observation for a few hours post-removal and a repeat abdominal XR to check for evidence of perforation

Disposition

• see Q7 below

In the case of this billiard ball, passing a Foley catheter beyond the object to release suction may be necessary. Gripping the ball may also be difficult. Vacuum devices or more invasive measures may be required.

Regarding the perianal block:
Rob Orman of ERCAST fame is the man I turn to when confronted with an anus problem, given his considerable experience with these issues … He describes the perianal block as an ‘auricular block of anus’ and finds it is usually successful. Infiltrate subcutaneously, pointing away from the rectum, by making 4 linear infiltrations in the shape of a box around the anus. Easy, eh. But, don’t try it at home kids…

Check out this fantastic short ‘procedurette video’ by Whit Fisher which shows how to create a suction device out of a neonatal suction bulb and how to break suction by passing a foley catheter:

Disposition depends on the nature of the foreign body, the success of the removal attempts, the presence of complications, and the patient’s mental state.

Disposition

• Successful removal in the ED —
  consider need for review by mental health team, sexual assault team and the social work team.
  provide written and verbal patient advice
  contact GP (phone/ fax/ letter) and arrange follow up, ideally the next day
  ensure careful documentation (especially if forensic issues)
• Body packers —
  consult toxicology and general surgery
  admit for consideration of whole bowel irrigation +/- endoscopic/ surgical removal
• Foreign body unable to be removed in the ED —
  admit under general surgery
  keep NBM pending possible transfer to the operating theatre

• Goldberg JE, Steele SR. Rectal foreign bodies. Surg Clin North Am. 2010 Feb;90(1):173-84, PMID: 20109641.
• Life in the Fast Lane. Top 10 Foreign Bodies
• Procedurettes by Whit Fisher — Rectal Regrets