Anorectal Foreign Body Removal

imagesAnorectal foreign body (FB) in a stable, cooperative patient, which is:


   imagesPalpable by rectal approach


   imagesAbsence of a sharp edge


CONTRAINDICATIONS



imagesObtain surgical consult immediately in following instances:


   imagesSigns of perforation, obstruction, or severe abdominal pain


   imagesNonpalpable FB


   imagesBroken glass in rectum


   imagesUncooperative or intolerant patient


   imagesLack of equipment necessary for retrieval



imagesGeneral Basic Steps


   imagesDetermine type of FB


   imagesRadiography


   imagesObtain necessary equipment


   imagesPatient preparation


   imagesAnalgesia


   imagesFB removal


   imagesAssess for structural damage


KEY ELEMENTS OF HISTORY



imagesIngestion (e.g., bones, toothpicks) versus rectal insertion


imagesSize and composition of FB


imagesTime of ingestion/insertion


imagesAttempts made to remove FB


imagesAssess for red flags—fever, abdominal pain, hematochezia


imagesAssess for sexual/physical assault, sexually transmitted disease (STD) risk


LANDMARKS



imagesDetermine the orientation, location, and composition of the anorectal FB and, thereby the appropriate approach to removal by the following:


   imagesDetailed history


   imagesConsider radiography


      imagesKidney, ureter, and bladder (KUB) x-ray


      imagesChest x-ray for free air detection (if concerned about perforation)


   imagesPhysical examination, including digital rectal examination (DRE)


imagesVisualization of the anorectum is enhanced with the patient in the lateral decubitus position, lithotomy position, or prone with knees tucked into chest


TECHNIQUE



imagesEquipment


   imagesDepends on the composition and locale of the FB but may include:


      imagesAnesthesia/analgesia


      imagesLight source


      imagesSpeculum (i.e., vaginal speculum or anoscope) or Parks retractor to improve visualization


      imagesRing and/or tenaculum forceps


      imagesFoley catheter and/or endotracheal tube (ETT)


      imagesVacuum extractor


imagesPatient Preparation


   imagesGet informed consent detailing risks, benefits, and alternatives


   imagesOrder KUB x-ray to localize and define FB, and to assess for obstruction or perforation if clinically necessary (FIGURE 83.1)


   imagesParenteral sedation and analgesia to enable relaxation and tolerance of the procedure. Avoid oversedation because the patient must be alert to assist in the delivery of the FB.


   imagesPlace the patient in the desired position


   imagesA perianal block may facilitate further sphincter relaxation. This is achieved by superficial injection of local anesthetic (≤1.5 mg/kg of 0.5% bupivacaine or ≤7 mg/kg of 1% lidocaine with 1:100,000 epinephrine) in a ring around the anus.


imagesExamination


   imagesExternal examination: Assess for signs of trauma


   imagesDRE


      imagesGauge location and orientation of FB


      imagesAssess for discharge or bleeding


      imagesSmall, blunt FBs may be removed during DRE


   imagesAnoscopy


      imagesAssess for mucosal injury


      imagesVisualize FB


imagesRemoval of FB


   imagesAttempt delivery of the FB by applying suprapubic pressure in synchrony with the patient bearing down



images


FIGURE 83.1 X-ray of a retained rectal vibrator. (Courtesy of Heather Huffman–Dracht.)

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Anorectal Foreign Body Removal
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