• Registration
  • Login
JETem
  • Home
  • About
    • Aim and Scope
    • Our Team
    • Editorial Board
    • FAQ
  • Issues
    • Current Issue
    • Ahead of Print
    • Past Issues
  • Visual EM
    • Latest Visual EM
    • Search Visual EM
    • Thumbnail Library
  • For Authors
    • Instructions for Authors
    • Submit to JETem
    • Photo Consent
    • Policies
      • Peer Review Policy
      • Copyright Policy
      • Editorial Policy, Ethics and Responsibilities
      • Conflicts of Interest & Informed Consent
      • Open Access Policy
  • For Reviewers
    • Instructions for JETem Reviewers
    • Interested in Being a JETem Reviewer?
  • Topic
    • Abdominal / Gastroenterology
    • Administration
    • Board Review
    • Cardiology / Vascular
    • Clinical Informatics, Telehealth and Technology
    • Dermatology
    • EMS
    • Endocrine
    • ENT
    • Faculty Development
    • Genitourinary
    • Geriatrics
    • Hematology / Oncology
    • Infectious Disease
    • Miscellaneous
    • Neurology
    • Ob / Gyn
    • Ophthalmology
    • Orthopedics
    • Pediatrics
    • Procedures
    • Psychiatry
    • Renal / Electrolytes
    • Respiratory
    • Toxicology
    • Trauma
    • Ultrasound
    • Wellness
    • Wilderness
  • Modality
    • Curricula
    • Innovations
    • Lectures
    • Oral Boards
    • Podcasts
    • Simulation
    • Small Group Learning
    • Team Based Learning
    • Visual EM
  • Contact Us

Procedural Sedation for the removal of a rectal foreign body

John Costumbrado, MD, MPH*, Valerie Lew, BS* and David Wagner, MD*

*University of California Riverside, Department of Emergency Medicine, Riverside, CA

Correspondence should be addressed to John Costumbrado, MD, MPH at jcostumbrado@gmail.com

DOI: https://doi.org/10.21980/J81332Issue 3:2
Abdominal/GastroenterologyProceduresVisual EM
No ratings yet.

History of present illness:

A 40-year-old male with a history of intravenous drug use presented to the emergency department (ED) for one week of constant lower abdominal pain associated with bloody stool. He denied fever, nausea, vomiting, urinary symptoms, and testicular pain or swelling. On exam, vital signs were within normal limits. Abdominal exam was non-tender without rebound or guarding. Rectal exam was negative for occult blood but positive for a palpable firm, blunt object. A computed tomography (CT) of the abdomen and pelvis was ordered to further investigate.

Significant findings:

Axial and coronal views on CT showed evidence of a large, tube-shaped foreign body in the rectum (see arrows) without evidence of acute gastrointestinal tract disease.

Discussion:

While rectal foreign bodies (RFB) are not uncommon to the ED, accurate epidemiological estimates are not available, due in part to underreporting.1 One study estimated an incidence of one patient per month that needed care for a RFB.2 Generally, patients can remove the object themselves; however, 20% of cases require endoscopic intervention and 1% require surgical intervention.3

RFBs can be removed via the transanal approach manually, instrument-assisted (eg, Kocher clamp, obstetric forceps), or endoscopically. In cases without intestinal perforation, transanal removal of a RFB is generally attempted as a first-line procedure in the ED, with an approximate success rate of 75%.4 However, the limitations of transanal removal depends on the location of the object, level of anal relaxation, and ability to grasp the object, which may be limited by the provider’s hand size and availability of instruments.Ways of facilitating bedside removal of RFBs include the Valsalva maneuver with proper positioning (i.e., lithotomy or prone knee-to-chest position) or manual abdominal wall compression to help move the object closer to the anal orifice. Anoscopy may also be used to improve visualization of the RFB. In some cases, RFBs can create a vacuum effect for which Foley catheters may be used to break the seal and provide additional traction. After the lubricated Foley passes proximal to the RFB and the balloon is inflated, gentle traction should be employed to move the object closer. Sedation can also be employed to decrease rectal tone and make the procedure more tolerable for the patient.

Complications prior to or during removal of the RFB include tearing of the rectal mucosa, perforation, infection, fecal incontinence, bladder and vessel injury or migration of the RFB to the chest wall.3,5 Uncontrollable rectal bleeding, peritonitis, or perforation are contraindications to ED RFB removal and warrant surgery or gastroenterology consultation. General anesthesia can be used for laparotomy with single incision to remove RFBs in the operating room.2

In this case, procedural sedation was utilized to facilitate removal of the object. Ketamine (2 mg/kg intravenously) was initially proposed, but due to concerns of the patient’s history of drug abuse, alternatives were considered. While Ketamine is generally well-tolerated, the incidence of dysphoric reactions has been estimated to occur in 10%-20% of patients.6 There is also some evidence that patients with a history of drug abuse may be more likely to have tolerance to Ketamine that requires higher dosing.7 Taking these factors into account, Etomidate (0.2 mg/kg intravenously) was used instead with favorable results. A metallic flashlight was removed by grasping the object with a combination of forceps and manual manipulation. After RFB removal, sigmoidoscopy was recommended to assess for rectal mucosal injuries or tears.8 No additional injuries were found on sigmoidoscopy and the patient tolerated the procedure well without complications.

Topics:

Abdominal pain, computed tomography, CT, foreign body, procedural sedation.

References:

  1. Tupe CL, Pham TV. Anorectal complaints in the emergency department. Emerg Med Clin North Am. 2016;34(2):251-270.doi: 1016/j.emc.2015.12.013
  2. Lake JP, Essani R, Petrone P, Kaiser AM, Asensio J, Beart RW. Management of retained colorectal foreign bodies: predictors of operative intervention. Dis Colon Rectum. 2004;47(10):1694-1698.
  3. Anderson KL, Dean AJ. Foreign bodies in the gastrointestinal tract and anorectal emergencies. Emerg Med Clin North Am. 2011;29(2):369–400. doi: 10.1016/j.emc.2011.01.009
  4. Mikami H, Ishimura N, Oka A, et al. Successful transanal removal of a rectal foreign body by abdominal compression under endoscopic and x-ray fluoroscopic observation: a case report. Case Rep Gastroenterol. 2016;10(3):646-652. doi:10.1159/000452210
  5. Goldberg JE, Steele SR. Rectal foreign bodies. Surg Clin North Am. 2010;90(1):173-184.  doi: 10.1016/j.suc.2009.10.004
  6. Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med. 2008;26(9):985-1028. doi: 1016/j.ajem.2007.12.005
  7. Farkas, J. The ketamine-tolerant patient. Available on: https://emcrit.org/pulmcrit/ketamine-tolerance/. Published September 11, 2017. Accessed October 10, 2017.
  8. Cohen JS, Sackier JM. Management of colorectal foreign bodies. J R Coll Surg Edinb. 1996;41(5):312-315.
Icon

Rectal Foreign Body - Case Report

1 file(s) 532 KB
Download
Icon

Rectal Foreign Body - Images

1 file(s) 494 KB
Download
CTIssue 3:2

Reviews:

No ratings yet.

Please rate this





Glass Foreign Body Hand Radiograph

13 Apr, 18

Evaluation of Snake Bites with Bedside...

13 Apr, 18
JETem is an online, open access, peer-reviewed journal-repository for EM educators

Most Viewed

  • Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema
  • Anticholinergic Toxicity in the Emergency Department
  • The Suicidal Patient in the Emergency Department Team-Based Learning Activity
  • Child Maltreatment Education: Utilizing an Escape Room Activity to Engage Learners on a Sensitive Topic
  • Acute Chest Syndrome

Visit Our Collaborators

About

Education

Learners should benefit from active learning. JETem accepts submissions of team-based learning, small group learning, simulation, podcasts, lectures, innovations, curricula, question sets, and visualEM.

Scholarship

We believe educators should advance through the scholarship of their educational work. JETem gives educators the opportunity to publish scholarly academic work so that it may be widely distributed, thereby increasing the significance of their results.

Links

  • Home
  • Aim and Scope
  • Current Issue
  • For Reviewers
  • Instructions for Authors
  • Contact Us

Newsletter

Sign up to receive updates from JETem regarding newly published issues and findings.

Copyright © 2016 JETem. All rights reserved.