Rectal Foreign Body: A Surgical Challenge

Rectal foreign bodies present the modern surgeon with a difficult management dilemma. Reluctance to seek medical help and to provide details about the incident often makes diagnosis difficult. Management of these patients may be challenging, as presentation is usually delayed after multiple attempts at removal by the patient themselves. Here we present a case of 35 year old male who presented in emergency with history of assault and forceful insertion of a glass bottle high up in his rectum. Minakshi Gadhire*, Sarika Mayekar**, Mansha Singh***, Prashant Rao**, Mohan A. Joshi**** Case Reports Bombay Hospital Journal, Vol. 57, No. 3, 2015 320 bottle was retrieved. Enterotomy site was closed with mersilk 2-0 in 2 layers. Post-operative course was uneventful. Patient discharged on fifth day following surgery. XRay showing glass bottle high up in rectum Intra-Operative photo showing Enterotomy with glass bottle inside Discussion In today's world both in and outside India rectal foreign bodies, though rather infrequent, are no longer considered as clinical oddities in emergency care medicine. It appears that their incidence is increasing, specifically in urban 1,2 population. The literature is replete with numerous case reports and case series of rectal foreign body in patients of all ages, 3 genders and ethnicities. Majority are male 1,2 in their 3rd and 4th decades. The foreign body commonly reported were plastic or glass bottles, cucumber, carrots, wooden or rubber objects etc. with intentions varying from sexual gratification to attempts at removing impacted faeces to assault. Rarely such can occur due to accidental events. The object length varied between 6 and 15 cm and larger and sharper object were prone for causing 4 complications. Patients usually presents with pelvic pain, bleeding per rectum or per rectal mucus discharge. Abdominal pain usually denotes perforation above the level of peritoneal reflection. Patients may even present with incontinence or bowel obstruction as the presenting system. Physical examination is centred on ruling out peritonitis. Rectal examination should be performed only after an X-ray of the abdomen to rule out a sharp object which may harm the examiner. It should include assessment of the distance of the rectal foreign body from anal verge and sphincter competency. Rigid proctoscopy is done for foreign bodies high up in rectum, when digital examination is insufficient to assess degree of rectal mucosal injury and to assess the foreign body and its distance from anal verge. Hard objects are potentially traumatic and 5 tend to migrate upwards. An attempt at manual extraction trans-anally should be made. Intravenous conscious sedation may be needed to keep patient relaxed, decrease anal sphincter spasm, improve visualisation and thus improves chances 6 of successful retrieval. Obstetric forceps can be used for extraction of foreign body with broad base having the patient perform Valsalva manoeuvre during the 7,8 attempt may facilitate the process. Colonoscopic removal is also reported with 9 good success for smaller size objects. However limited studies in literature restrict the definition of major role of Bombay Hospital Journal, Vol. 57, No. 3, 2015 321 colonoscopy. Laparotomy is only required in impacted foreign bodies and which are larger than 10 cm, hard or sharp, or located in the proximal rectum or distal 2,5 sigmoid and or associated with perforative peritonitis. Even with laparotomy the aim should be trans-anal removal by trans-abdominal a n d t r a n s a n a l m a n i p u l a t i o n . Postretrieval colonoscopy is mandatory to rule out colorectal injury upon successful 10 trans-anal extraction. If attempts at trans-anal retrieval has failed then an enterotomy may need to be created. In cases of foreign bodies causing perforation closure of perforation with proximal diverting colostomy can be done. Diversion should be specially considered in patients with delayed presentation, significant faecal contamination, signs of sepsis and haemodynamic instability. A case has been reported where symphysiotomy has also been done even when trans10 abdominal approach failed. However in our case we could remove the impacted glass bottle by creating an enterotomy after repeated failed attempts at trans-anal retrieval. So to conclude we would like to emphasise the fact that rectal foreign body even in today's modern era with vast literature for its management available still creates a dilemma in the minds of the surgeon, as every patient presents with a different foreign body with different time since insertion, challenging the surgeon to use innovative therapeutic approaches for its extraction. And to end I would like to quote a statement from Bailey and Love's textbook Short Practice Of Surgery "The variety of foreign bodies that have found their way into the rectum is hardly less remarkable than the ingenuity displayed in their removal."