Case Report
Copyright ©2008 The WJG Press and Baishideng. All rights reserved.
World J Gastroenterol. Jul 21, 2008; 14(27): 4403-4406
Published online Jul 21, 2008. doi: 10.3748/wjg.14.4403
Management of rectal foreign bodies: Description of a new technique and clinical practice guidelines
Jan J Koornstra, Rinse K Weersma
Jan J Koornstra, Rinse K Weersma, Department of Gastroenterology & Hepatology, University Medical Centre Groningen, University of Groningen, Groningen RB 9700, The Netherlands
Author contributions: Koornstra JJ and Weersma RK were responsible for the design of the paper and patient care and wrote the manuscript; Koornstra JJ performed the systematic literature search.
Correspondence to: Dr. Jan J Koornstra, Department of Gastroenterology & Hepatology, University Medical Centre Groningen, University of Groningen, PO Box 30001, Groningen RB 9700, The Netherlands. j.j.koornstra@int.umcg.nl
Telephone: +31-50-3613354
Fax: +31-50-3619306
Received: April 9, 2008
Revised: May 10, 2008
Accepted: May 17, 2008
Published online: July 21, 2008

Abstract

A number of techniques have been described to remove rectal foreign bodies. In this report, a novel endoscopic technique using a pneumatic dilatation balloon normally used in achalasia patients is presented. In addition, a systematic review of the literature was performed for non-operative methods to remove foreign bodies from the rectum. These results are summarised, presented as a practical at-a-glance overview and a flow chart is offered to guide the clinician in treatment decisions. The design of the flow chart was based on the aims to treat the patient preferably on an outpatient basis with minimally invasive techniques and if possible under conscious sedation rather than general anaesthesia.

Key Words: Foreign body, Rectum, Rectal, Removal, Review



INTRODUCTION

Intentional or unintentional insertion of rectal foreign bodies is not uncommon and often poses a serious challenge on the clinician. Objects can be inserted for diagnostic or therapeutic purposes, or self-treatment of anorectal disease, by criminal assault and accident or, most commonly, for sexual purposes. Most patients with rectal foreign bodies present to the emergency room usually after efforts to remove the object at home. Many endoscopic and surgical techniques to remove rectal foreign bodies have been described in the literature and the reported variety in foreign bodies is as large as the number of techniques used to remove them[146]. The descriptions in the available literature are anecdotic and consist largely of case reports or case series[146].

In this report, a novel endoscopic technique to remove rectal foreign bodies using a pneumatic dilatation balloon normally used in achalasia patients is presented. In addition, a systematic review of the literature was performed for non-operative methods to remove foreign bodies from the rectum. These results are summarized and a practical flow chart is presented to guide the clinician in his or her treatment decisions.

CASE REPORT

A 19-year-old man presented at the emergency department, 12 h after insertion of a high pressure container with tanning spray into his rectum. A plain abdominal radiograph (Figure 1) showed the container in the rectosigmoid region. There were no signs of perforation. A flexible sigmoidoscopy was performed under conscious sedation. The object was located just above the rectosigmoid junction. The container could not be extracted by bimanual manipulation. An attempt to remove the object with conventional endoscopic instruments, such as polypectomy snares, was unsuccessful.

Figure 1
Figure 1 Plain abdominal radiograph showing the foreign body impacted in the rectosigmoid.

The sigmoidoscope could be passed alongside the foreign body to its proximal end. A guide wire was left behind with the sigmoidoscope removed. Subsequently, a 40 mm pneumatic dilatation balloon (Rigiflex®, Boston Scientific), normally used in achalasia patients, was inserted over the guide wire and inflated just above the container (Figure 2). For safety purposes, the sigmoidoscope was reintroduced alongside the catheter of the balloon to allow endoscopic visual control of the distal end of the container in the rectum. Gentle traction was exerted on the balloon catheter, and the container was successfully removed under fluoroscopic and endoscopic control (Figure 3).

Figure 2
Figure 2 Lateral view of abdominal radiograph depicting the foreign body with the achalasia balloon inflated just above the container.
Figure 3
Figure 3 The removed container.
DISCUSSION

A large number of surgical and non-surgical techniques have been described to remove rectal foreign bodies[146]. Our case illustrates that for removal of foreign bodies retained in the rectosigmoid, extraction with a pneumatic dilatation balloon, inflated above the foreign body, may be an elegant and safe alternative when conventional techniques fail. Our technique has not been described before as revealed by a systematic review of the literature. We performed a systematic PubMed search from 1966 to present, using the search terms ‘rectal’, ‘rectum’, ‘colorectal’, ‘foreign’, ‘bodies’ and ‘endoscopic’. Only reports in English were included. The results of the systematic search of the literature, specified for the type of foreign body, are summarized in Table 1[136]. Table 1 also summarizes endoscopic techniques and non-endoscopic techniques for removing foreign bodies. In addition to the reports presented in the Table 1, several case series have been published without detailed information on the techniques used to remove various foreign bodies[1822253746].

Table 1 Overview of reports on endoscopic and non-endoscopic removal of rectal foreign bodies.
Type foreign bodyTechniqueAnaesthesiaAuthor[Ref.]
Ballpoint penPolypectomy snare1-Richter[1]
Water filled balloonPuncture and forceps1-Wolf[2]
Chicken bonePolypectomy snare1-Tarnasky[3]
ToothpickPolypectomy snare1-Over[4]
AppleDefragmentation by APC1NoneGlaser[5]
Glass bottleBiopsy forceps1GeneralHuang[6]
VibratorPolypectomy snare1NoneHuang[6]
Glass test tubeInflated Sengstaken tube1-Hughes[7]
Test tubePolypectomy snare1-Kantarian[8]
Enema tipPolypectomy snare1-Kantarian[8]
VibratorPolypectomy snare, biopsy forceps1-Kantarian[8]
PencilPolypectomy snare1-Vemula[9]
Iron bar2-channel colonoscope and wires1-Ahmed[10]
Bottle neckInflated Foley cathether1GeneralHumes[11]
Spray containerAchalasia balloon1NonePresent report
Spongy toy ballObstetric vacuum extractorGeneralFeigelson[12]
VibratorObstetrical forceps, anal dilationLocalHaft[13]
VibratorUterine vulsellumLocalLevin[14]
Aftershave bottleRubber-shod bone olding clampSpinalSiroospour[15]
Chicken boneDigitallyNoneDavies[16]
Aerosol-can CapTenaculum forceps, anal dilatationGeneralAquino[17]
VaseFilling with plasterGeneralCouch[18]
Glass jarExtraction with plaster rollsSpinalGraves[19]
Glass jarEndotracheal tube, anal dilationLocalGarber[20]
AppleBimanual manipulationLocalSharma[21]
Glass jarInflated Foley catheterGeneralYaman[22]
Glass bottleObstetric vacuum cupGeneralMacKinnon[23]
Glass bulb3 inflated Foley catheters-Diwan[24]
ThermometerBiopsy forcepsGeneralHuang[6]
VibratorTransanal Kocher clampsLocalHuang[6]
Bowling bottleObstetric forcepsGeneralHuang[6]
Perfume bottleManuallySpinalBusch[25]
Piece of woodManuallyGeneralJansen[26]
Toothbrush caseInflated Fogarty catheter-Wigle[27]
Oven mittForceps after anal dilationGeneralLosanoff[28]
Sink waste pipeObstetric forcepsGeneralPeet[29]
Metallic bouleElectromagnetGeneralCoulson[30]
CarrotMyomectomy screw-Vashist[31]
GlassObstetric vacuum extractorSpinalJohnson[32]
Rubber ballManual extraction, anal dilationGeneralNivatvongs[33]
Wooden rodBimanually, anal dilationSpinalNivatvongs[33]
BottleManually after anal dilationGeneralGopal[34]
DildoMyomectomy screw-Clark[35]
Light bulbAbdominal compressionSpinalKonishi[36]

An algorithm was provided to guide the clinician in his or her treatment decisions, partly based on the methods presented in the Table 1 (Figure 4). We included only those methods most commonly used and excluded rare treatment variants.

Figure 4
Figure 4 Algorithm for the removal of a colorectal foreign body.

The first step in the evaluation is that one should always be aware of the possibility of a large bowel perforation and perform radiological investigations. Plain abdominal radiography or water soluble contrast enemas may be helpful. An abdominal X-ray will also provide information on the localization of the foreign body, whether it is below or above the rectosigmoid junction. If perforation of the bowel has occurred, immediate laparotomy is warranted. If there are no signs of perforation, several management approaches can be tried. Our aim was to treat the patient on an outpatient basis with minimally invasive techniques and preferably under conscious sedation instead of general anaesthesia.

First, digital removal of the object should be attempted, if necessary with the patient at different positions. If this approach fails, one can try bimanual manipulation. The next step is the insertion of an endoscope with subsequent attempts to grasp the foreign body with regular endoscopy accessories like polypectomy snares. When this fails, it may be helpful to use devices that can be inflated in the rectosigmoid, such as a Foley catheter or an achalasia balloon. Such a device prevents a vacuum that might develop upon extraction of the foreign body and may also be directly used to remove the object.

If these interventions fail, we refer the patients to the operating theatre. Full relaxation of the anal sphincter muscles can be achieved by local, spinal or general anaesthesia. Sometimes, bimanual manipulation of the relaxed abdominal wall under spinal or general anaesthesia may evade surgery. Patients should be consented for a laparotomy prior to general anaesthesia should the manual or endoscopic removal fail.

Finally, when conservative measures fail, laparoscopic or laparotomic approaches are indicated. After removal, sigmoidoscopy is generally recommended to rule out perforations. In the largest series of patients with rectal foreign bodies described thus far (n = 93), it was found that objects retained for more than 2 days, those larger than 10 cm and those located proximal to the rectum increase the likelihood of surgery[37].

In conclusion, many techniques are available for the extraction of rectal foreign bodies. If possible, patients should be treated with minimally invasive techniques and preferably on an outpatient basis under conscious sedation.

Footnotes

Peer reviewer: Fabio Pace, Professor, “L. Sacco” University Hospital, Via G. B. Grassi, 74, Milano 20157, Italy

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