ABSTRACT

CORRESPONDING AUTHOR:
Dr. Narender Kumar,
MBBS-Intern,
Sardar Patel Medical College,
Bikaner, India.
Email: narender8189@gmail.com

ABSTRACT: INTRODUCTION: Rectal foreign bodies are common, but foreign body made of glass with uneven sharp distal end and complicated with hypovolemic shock is very rare. It is very challenging to be removed by laparotomy and poses extra difficulty in emergency. PRESENTATION OF CASE: A 45-year-old man with complains of rectal foreign body and bleeding per rectum reported in emergency room. On examination patient was in hypovolemic shock and continuous bleeding through anal opening. Emergency laparotomy was per-formed and foreign body was retrieved successfully. DISCUSSION: Rectal foreign body made of glass with uneven sharp distal end towards distal end of rectum is very rare. Retrieval of these foreign bodies will be very difficult, especially for the emergency cases that are complicated with hypovolemic shock. Emergency laparotomy can be successfully performed to stop the bleeding and minimize rectal and anal canal trauma. To the best of our knowledge, such rectal foreign body has been rarely reported. CONCLUSION: Rectal foreign body with uneven sharp edges towards anal opening are difficult to retrieve trough transanal route. Hypovolemic shock due to bleeding and rectal perforation is major complications of these foreign bodies. Emergency laparotomy should be done in these cases.

KEYWORDS: Rectum, Foreign Body, hypovolemic shock, Laparotomy.

INTRODUCTION: Rectal foreign bodies are reported commonly in medical practice.^1,2 The majority of objects fruits, vegetables, bottles, vibrators, candles and dildos are inserted by self- introduction in children, psychiatric patients, in victims of assault and as a result of sexual gratification.³ It causes lower abdominal pain; rectal bleeding and can perforate rectum and other structures.⁴ Rectal perforation and peritonitis must be ruled out before manipulation of a foreign body.⁵ Retrieval of the foreign body from rectum has always been a challenge; and numerous approaches have been devised. If difficulty is experienced in retrieving the foreign body in the rectum, a laparotomy is usually necessary.⁶

CASE REPORT: A 45 year old male, referred from primary health centre; reported to the emergency room, with complaints of foreign body [made of glass] in rectum and per rectum bleeding for 12 hours. Bleeding was mild but continuous, resulted in hypovolemic shock. The signs and symptoms of mechanical intestinal obstruction and colorectal perforation were absent.

Patient was inserting foreign body through anal opening for sexual gratification, early hours in the morning; resulted in retention of the foreign body in the rectum. He and her wife had attempted to retrieve the foreign body but failed and broke the open margin of the foreign body and made its edge unevenly sharp, sharp edges were towards anal opening; which creates it difficult to retrieve through anal opening. Sharp edges of foreign body resulted in injury in the rectal mucosa and bleeding started. Patient reported to the nearby doctor, who tried to stop the bleeding by packing the site of bleeding by gauge pieces and referred the patient.

Rectal examination after removing gauge piece shows that bleeding was not stopped and foreign body approximately 6 cm above the anal opening. Abdominal examination was unremarkable. Rectal perforation and peritonitis were clinically ruled out before manipulation. Patient was in state of hypovolemic shock, in the emergency room surgeon started intravenous fluids and blood transfusion; and shifted the patient to emergency operation room.

Laparotomy was performed for retrieval of foreign body. After exploration by lower midline laparotomy incision, foreign body [glass cup] was palpated at middle part of rectum by finger and then incision in anterior wall of rectum was given. Foreign body was gripped by its distal, closed blunt end with fingers of surgeon and retrieved through the incised site through anterior wall of rectum.

Dimensions of foreign body were height 8 cm, diameter of open end 6 cm and closed end 4 cm. Primary rectal repairs was done in single layer with silk 2.0 round body sutures, and diversion colostomy was performed because the repair site was edematous. An abdominal drain was placed in pelvis. Per rectum examination did not reveal any residual foreign body. His post-operative period was uneventful. The abdominal drain was removed after 48 hours and patient started oral liquid diet.

 The patient was discharged after 7^th post-operative day.

DISCUSSION: Rectal foreign bodies are reported in medical practice in emergency department commonly in certain settings.⁷ A careful history and rectal and abdominal examination allows palpation of foreign body and also helps to diagnose the possible complications caused by foreign body.⁸ Rectal perforation and peritonitis are major complications of sharp foreign bodies⁹. Radiological investigations are helpful in determining the presence, number, size, shape, location and direction of foreign body.¹⁰ This information is used in planning and management of extraction maneuver.

Management of rectal foreign body is more challenging and depends on a particular presentation of the object.¹¹ Most retained rectal foreign bodies can be successfully extracted transanally under appropriate anesthesia and only a small proportion, mostly cases of perforation, overt peritonitis, pelvic sepsis or for failure of transanal extraction, will require open surgery or laparoscopy.¹² Foreign bodies made of glass should be considered for special attention; the object should be removed intact without breaking it.

A broken foreign body made of glass should be retrieved with special care with minimal injuries to nearby structures. All the patients should be referred for psychological evaluation to avoid similar problem in future and to minimize the psychological trauma to patients in assault cases.

CONCLUSION: Foreign body in rectum with continuous bleeding and hypovolemic shock presents as an emergency life threatening problem. Rectal foreign body with uneven sharp edges towards anal opening are difficult to retrieve trough transanal route. Emergency laparotomy should be done in these cases to retrieve these foreign bodies by trans abdominal approach in a retrograde maneuver to minimize the rectum and anal canal trauma. Hypovolemic shock should be managed by intra venous fluids and blood transfusion.

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Image 1: closed end of foreign body (made of glass) in rectum.

Image 1

Image 2: Retrieved rectal foreign body.

Image 2