Management of rectal foreign bodies: Description of a new technique and clinical practice guidelines

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[1–46]. The descriptions in the available literature are anecdotic and consist largely of case reports or case series[1–46].

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 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 Lateral view of abdominal radiograph depicting the foreign body with the achalasia balloon inflated just above the container.

Figure 3 The removed container.

DISCUSSION

A large number of surgical and non-surgical techniques have been described to remove rectal foreign bodies[1–46]. 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[1–36]. 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[18222537–46].

Table 1 Overview of reports on endoscopic and non-endoscopic removal of rectal foreign bodies.

Type foreign body	Technique	Anaesthesia	Author[Ref.]
Ballpoint pen	Polypectomy snare1	-	Richter[1]
Water filled balloon	Puncture and forceps1	-	Wolf[2]
Chicken bone	Polypectomy snare1	-	Tarnasky[3]
Toothpick	Polypectomy snare1	-	Over[4]
Apple	Defragmentation by APC1	None	Glaser[5]
Glass bottle	Biopsy forceps1	General	Huang[6]
Vibrator	Polypectomy snare1	None	Huang[6]
Glass test tube	Inflated Sengstaken tube1	-	Hughes[7]
Test tube	Polypectomy snare1	-	Kantarian[8]
Enema tip	Polypectomy snare1	-	Kantarian[8]
Vibrator	Polypectomy snare, biopsy forceps1	-	Kantarian[8]
Pencil	Polypectomy snare1	-	Vemula[9]
Iron bar	2-channel colonoscope and wires1	-	Ahmed[10]
Bottle neck	Inflated Foley cathether1	General	Humes[11]
Spray container	Achalasia balloon1	None	Present report
Spongy toy ball	Obstetric vacuum extractor	General	Feigelson[12]
Vibrator	Obstetrical forceps, anal dilation	Local	Haft[13]
Vibrator	Uterine vulsellum	Local	Levin[14]
Aftershave bottle	Rubber-shod bone olding clamp	Spinal	Siroospour[15]
Chicken bone	Digitally	None	Davies[16]
Aerosol-can Cap	Tenaculum forceps, anal dilatation	General	Aquino[17]
Vase	Filling with plaster	General	Couch[18]
Glass jar	Extraction with plaster rolls	Spinal	Graves[19]
Glass jar	Endotracheal tube, anal dilation	Local	Garber[20]
Apple	Bimanual manipulation	Local	Sharma[21]
Glass jar	Inflated Foley catheter	General	Yaman[22]
Glass bottle	Obstetric vacuum cup	General	MacKinnon[23]
Glass bulb	3 inflated Foley catheters	-	Diwan[24]
Thermometer	Biopsy forceps	General	Huang[6]
Vibrator	Transanal Kocher clamps	Local	Huang[6]
Bowling bottle	Obstetric forceps	General	Huang[6]
Perfume bottle	Manually	Spinal	Busch[25]
Piece of wood	Manually	General	Jansen[26]
Toothbrush case	Inflated Fogarty catheter	-	Wigle[27]
Oven mitt	Forceps after anal dilation	General	Losanoff[28]
Sink waste pipe	Obstetric forceps	General	Peet[29]
Metallic boule	Electromagnet	General	Coulson[30]
Carrot	Myomectomy screw	-	Vashist[31]
Glass	Obstetric vacuum extractor	Spinal	Johnson[32]
Rubber ball	Manual extraction, anal dilation	General	Nivatvongs[33]
Wooden rod	Bimanually, anal dilation	Spinal	Nivatvongs[33]
Bottle	Manually after anal dilation	General	Gopal[34]
Dildo	Myomectomy screw	-	Clark[35]
Light bulb	Abdominal compression	Spinal	Konishi[36]

-: No description; APC: Argon-plasma coagulation;

¹Endoscopic removal of rectal foreign bodies.

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 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.