unusual fb in rectum niaz-ud-din & muhammad saaiq

An Unusual Foreign Body in the Rectum Niaz-ud-Din et.al.

Case Report

An Unusual Foreign Body in the Rectum A middle aged heroin addict who presented to Accident and emergency department with two hours history of rectal impaction of a long bathroom brush is described. He had introduced it himself for achieving sexual gratification. It was removed under spinal anaesthesia. The patient had uneventful recovery in the immediate postoperative phase. Key words: Rectal foreign body. Anal eroticism.

Niaz-ud-Din Muhammad Saaiq Muhammad Zubair Aatif Inam Shabana Jamal Tanwir Khaliq Department of General surgery PIMS , Islamabad. Address for Correspondence: Dr Niaz-ud-Din Postgraduate Resident Department of General surgery PIMS , Islamabad. E-mail: [email protected]

Introduction

As such foreign body ( FB ) in the rectum is not

uncommon and hence no longer considered rare.1 It can be caused by anal eroticism, concealment of illegal drugs, attention-seeking behaviour, assault, accident and occasionally retained ingested foreign bodies.2,3 It can also be observed in prisoners, psychiatric patients, homicide and suicide attempts, erotic acts, homosexuals, sadomasochistic practice, cases of sexual aggression or rape, people under the effects of drugs or alcohol and drug carriers.4

A host of different foreign bodies with various sizes and shapes have been described, including glass bottles, aerosol cans, light bulbs, corn cobs, vibrators, hosepipes, primus stoves and packets of marijuana.1

Case Report A 54 years old man presented to the accident

and emergency department of PIMS, Islamabad with pain in the rectum and inability to walk and sit up. On further questioning, he admitted that he had a foreign body in the rectum, in fact a long bathroom brush which he had introduced into the rectum for achieving sexual gratification. He had been a heroin addict since long and had been admitted to rehabilitation centre over the last six months. He was married with four children and was accompanied by a social worker.

On physical examination he was vitally stable and abdomen was soft and non-tender with bowel sounds audible. On examination of the perianal area, there was a long bathroom brush (Figures III and IV) inserted into the rectum and was firmly impacted inside.

An effort was made in the emergency department to remove the foreign body but failed. Consent was taken for possible laparotomy / colostomy and the patient was shifted to operation theatre, where the FB was removed under spinal anaesthesia in lithotomy position. The rectal mucosa was firmly impacted into the hook of the brush. Post operatively the patient was shifted to surgical ward for observation but he left the ward against the medical advice at night.

Discussion A variety of foreign bodies with various sizes

and shapes have been described. The condition can be classified according to the level with respect to the rectosigmoid junction. Low-lying foreign bodies are those located inside the rectal ampulla, whereas high-lying foreign bodies lie at or above the rectosigmoid junction. This classification has been used as a general rule to guide the method of retrieval.5-7 The FB can be diagnosed by history, physical examination (mainly by digital rectal examination) and confirmed by plain abdominal radiographs. For uncomplicated low-lying foreign bodies, transanal extraction can be achieved by digital manipulation or using various grasping forceps through proctoscopy, anal retractor or rigid sigmoidoscopy. A vacuum is built up proximal to the foreign body preventing its extraction, a Foley catheter could be passed proximal to it to overcome the negative pressure. As anal spasm can hold the foreign body away from anus, adequate relaxation is often needed. In difficult cases, extraction may require complete relaxation of anal sphincters by local, regional or even general anaesthesia.8-10

Ann. Pak. Inst. Med. Sci. 2008; 4(1): 62-63 62


Figure I: Preoperative picture of the patient with FB in situ.

Figure II: Lithotomy position of the patient with FB in situ.

Figure III: The retrieved FB .

Figure IV: Hook of the brush into which rectal mucosa was firmly impacted.

For high-lying foreign bodies, trans-anal

extraction can still be successful, but they are more likely to require a general anaesthesia. For patients presenting with frank peritonitis, laparotomy is mandatory to remove the foreign body, repair the perforation and perform surgical lavage. A defunctioning stoma may sometimes be needed. 7-10

It is imperative not to humiliate or belittle these patients and to treat them with the same amount of respect we normally show to other patients approaching us for help. Psychologist and psychiatrist help /support should also be sought while managing such cases.

References

1. Cheung YS, Wong J, Wilson WC Ng, Tam TL, Micah CK Chan, Paul BS. Retrieval of rectal foreign bodies: a difficult case. Surgical Practice 2007 : 11 : 162–4.

2. Eisen GM, Baron TH, Dominitz JA . Guideline for the management of ingested foreign bodies. Gastrointest. Endosc. 2002; 55: 802–6.

3. Clarke DL, Buccimazza I, Anderson FA . Colorectal foreign bodies. Colorectal Dis. 2005; 7: 98–103.

4. Rodríguez-Hermosa JI, Codina-Cazador A, Ruiz B, Sirvent JM, Roig J, Farrés R.Management of foreign bodies in the rectum. Colorectal Disease 2007;9 : 543–8.

5. Cohen JS, Sackier JM. Management of colorectal foreign bodies. J R Coll Surg Edinb. 1996; 41: 312–5.

6. Kingsley AN, Abcarian H. Colorectal foreign bodies. Management update. Dis Colon Rectum 1985; 28: 941–4.

7. Lake JP, Essani R, Petrone P . Management of retained colorectal foreign bodies: predictors of operative intervention. Dis. Colon Rectum 2004; 47: 1694–8.

8. Huang WC, Jiang JK, Wang HS . Retained rectal foreign bodies. J Chin Med Assoc 2003; 66: 607–12.



9. Obrador A, Barranco L, Reyes J, Gayà J. Colorectal trauma caused by foreign bodies. Rev Esp Enferm Dig 2002; 94: 109–10.

10. Shah J, Majed A, Rosin D. Rectal salami. Int J Clin Pract. 2002 ; 56 : 558-9.


unusual fb in rectum niaz-ud-din & muhammad saaiq

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