Foreign bodies in the anus and rectum

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Classification according to ICD-10
T18.5 Foreign bodies in the anus and rectum
ICD-10 online (WHO version 2019)

A rectal foreign body , often rectal foreign body ( English rectal foreign body ), is a mostly through the anus into the rectum (rectum or Latin rectum introduced) and those under there object. It can become clinically relevant if it cannot be easily removed by the patient in the intended manner. The reverse route of a foreign body - intake via the mouth and passage through the entire gastrointestinal tract into the rectum - is rarely clinically relevant.

Overview of the human gastrointestinal tract:
1 =  esophagus , 2 =  stomach , 3 =  duodenum , 4 =  small intestine , 5 =  appendix , 6 =  appendix , 7 =  colon , 8 =  rectum , 9 =  anus  - internal sphincter muscle and External sphincter muscle

Rectal foreign bodies belong to the group of gastrointestinal foreign bodies (foreign bodies in the digestive organs).

frequency

X-ray of a plastic mineral water bottle that extends from the rectum to the sigmoid colon .

There are no reliable data on the incidence of clinically relevant rectal foreign bodies. It is likely to have increased over the long term and has recently become a phenomenon that has been observed more frequently. The number of unreported cases is probably very high.

Foreign bodies in the anus and rectum are much more common in men than in women. The gender ratio is approximately 28: 1. A 2010 meta-study found a gender ratio of approximately 37: 1. The mean age of the patients was 44.1 years with a standard deviation of 16.6 years.

The first case described in the literature dates back to the 16th century.

causes

The reasons for foreign bodies in the anus and rectum are very different, but in most cases they are sexually or criminally motivated. In the vast majority of cases, the foreign body is voluntarily inserted into the rectum. This primarily includes sexually motivated practices , which are the most common cause of clinically relevant rectal foreign bodies. Bodypacking , the illegal transport of drug containers in body orifices (here: in the rectum), is another - possibly - voluntary form of introducing foreign bodies into the anus and rectum. This also includes attempts to transport objects such as weapons, such as knives, or ammunition. In one study, sexual stimulation was responsible for about 80 percent of the cases where a foreign body in the anus and rectum became clinically relevant. Included in the 80 percent are around ten percent cases of sexual assault .

It is also rare that the patient himself introduces foreign bodies into the anus that can no longer be removed on their own in order to get the affection and pity of doctors and nurses. In these cases the behavior is assigned to Munchausen syndrome .

Another cause can be a supposed self-treatment of diseases. For example, one patient tried to treat stubborn diarrhea by inserting a corn cob into his rectum . Another patient tried to relieve the chronic itching ( pruritus ani ) caused by his hemorrhoid disease with the help of a toothbrush . The toothbrush got out of control and disappeared into his rectum.

Foreign objects can enter the rectum against the patient's will through accidents or torture . A mercury clinical thermometer that was inserted into the rectum to measure temperature and broke off is an example of an accidental foreign body. In ancient Greece, for example, there was a radish punishment for male adulterers , in which a radish was inserted into the anus of the adulterer . Many self-introduced foreign bodies are declared as accidents by the affected patients out of shame .

Foreign objects can easily become lodged in the rectum for several reasons. On the one hand, many of the objects used for sexual stimulation are conically shaped at their tips, so that easier penetration is guaranteed. At the end, however, they are mostly flat. If the end of the object passes the anus in the direction of the rectum, extraction by the person concerned is no longer possible in many cases. Often the object is inserted much deeper into the rectum than originally planned, in order to receive stronger stimulation. The sphincters then mechanically prevent the extraction of the foreign body.

Objects

Toothbrush cup in the rectum

The type and size of the rectal foreign bodies vary widely and in some cases exceed the anatomical-physiological imagination. ( see also: fisting )

The objects described in the specialist literature include, for example:

It doesn't always have to be solid objects. In 1987, for example, a case was described of a patient who administered an enema with a cement mixture . After the mixture solidified and wedged, the resulting cement chunk had to be surgically removed. Another extreme example occurred in November 1953. A depressed man inserted a six inch cardboard tube into his rectum and then threw a lit firework into the opening of the tube, tearing a large hole in his rectum.

diagnosis

X-ray showing a fragment of a bottle (bottle neck, in the picture above the pubic symphysis ) in the rectum of a patient.

For reasons of shame, many patients are reluctant to provide information about what happened when taking their anamnesis , so that information important for therapy may be missing. In addition, for the same reason, patients appear very late (“when there is no other way”) to see a doctor. A trusting, sensitive and caring care of the mostly very embarrassed and uncomfortable patients by the involved clinical staff is therefore of great importance for the success of the treatment and can possibly be life-saving.

Before removing the foreign body, radiological images are usually recorded in different projection planes in order to determine the exact position and depth of the foreign body. This is usually done by x-rays . In the case of foreign bodies made of materials that provide too little contrast in the X-ray image (e.g. objects made of solid plastic), sonography (ultrasound) or computed tomography can be used if necessary . The magnetic resonance imaging is particularly the case of unknown debris contraindicated . Foreign bodies introduced into the rectum may penetrate far into the colon, in some cases the right flexure .

An endoscopy , which can also be useful in therapy, enables the identification and location of the object in the rectum.

The information about the foreign body obtained in this way is very important for its removal, as perforation of the rectum and anus must be avoided at all costs .

therapy

Endoscope loop with the fragment of the glass bottle from the X-ray.

The therapeutic measures for removing the foreign body can be as varied as the objects in the rectum can be. Often the foreign bodies are made of fragile materials such as glass. In addition, it usually takes many hours or even days before the patient see a doctor. Before consulting a doctor, most patients try unsuccessfully several times to remove the foreign body themselves or through another layperson. In many cases this worsens the starting position for a successful extraction of the foreign body.

In most cases, the foreign body can be removed endoscopically. For example, vibrators can usually be grasped and removed from the rectum with a large polypectomy snare (usually used to remove polyps during colonoscopy ). Smaller objects, such as clinical thermometers , can also be extracted from the rectum using biopsy forceps . Large jammed objects often cannot be moved with a flexible endoscope. In these cases, rigid instruments are often better suited.

In some cases, instruments normally used for obstetrics have proven effective in removing the foreign body. These include the forceps (forceps) and the suction cup . Furthermore, wooden objects with corkscrews and drinking glasses were recovered after pouring plaster of paris. With the glasses, for example, a spoon can be poured into the still liquid plaster as an “anchor” and pulled out together with the glass after it has solidified. Light bulbs are usually covered with a mesh of bandage gauze , smashed in the rectum and then extracted.

The argon plasma coagulation has already been used successfully. The foreign body to be removed was a green apple wrapped in cellophane in the rectum of a 44-year-old patient. Argon plasma coagulation allowed the apple to shrink by over 50 percent of its size and ultimately to be removed. Previous extraction attempts with endoscopic instruments failed because of the smooth surface of the object.

If the foreign body cannot be extracted by any of the above measures because it is too high in the sigmoid colon , bed rest and sedation of the patient can cause the foreign body to descend back into the rectum in many cases. There the foreign body is easier to reach and easier to extract.

In more difficult cases, an abdominal incision (laparotomy) may be necessary. Statistically speaking, this is necessary in around 10 percent of the cases. The large intestine can then possibly be manipulated via the open abdomen in such a way that the foreign body migrates towards the anus and can be grasped there. The opening of the large intestine ( colotomy ) can be indicated in particularly difficult cases, especially if manipulation of the foreign body would seriously endanger the patient's health. This can be the case, for example, with jammed drug condoms.

anesthesia

In the lighter cases, sedation of the patient is usually sufficient . Local and spinal anesthesia are also often used. More difficult procedures are usually performed under anesthesia ; It is absolutely necessary when opening the abdominal cavity (laparotomy) and opening the colon (colotomy). Anesthetics for the relaxation of the sphincter muscles (sphincters) advantageous.

Aftercare

After the operation, a sigmoidoscopy is recommended - a colonoscopy in which 30 to 40 centimeters of the large intestine and rectum are examined with a flexible endoscope - in order to rule out possible perforations of the rectum and the sigmoid colon , or to detect injuries to the mucous membranes. In-patient follow-up is indicated in some cases.

Sample list

foreign body technology anesthesia source
pen Polypectomy snare k. A.
balloon filled with water Puncture k. A.
Chicken bones Polypectomy snare k. A.
toothpick Polypectomy snare k. A.
Apple in cellophane Defragmentation with APC no
glass bottle Biopsy forceps general anesthetic
vibrator Polypectomy snare no
Test tube inflated Sengstaken probe k. A.
Test tube Polypectomy snare k. A.
Tip of an enema Polypectomy snare k. A.
vibrator Biopsy forceps k. A.
pencil Polypectomy snare k. A.
Iron rod Two-channel colonoscope and wires k. A.
Bottleneck inflated Foley catheter general anesthetic
Spray container Achalasia balloon no
spongy toy ball Suction cup general anesthetic
vibrator Obstetric forceps and anal dilation Local anesthesia
vibrator Hook pliers Local anesthesia
Aftershave bottle Bone holding forceps with rubber feet Spinal anesthesia
Chicken bones with fingers no
Spray can lid pointed grasping forceps and anal dilatation general anesthetic
vase Filling in with plaster general anesthetic
Glass vessel Extraction with plaster of paris Spinal anesthesia
Glass vessel Endotracheal tube Local anesthesia
Apple two-handed editing Local anesthesia
Glass vessel inflated Foley catheter general anesthetic
glass bottle Suction cup general anesthetic
100 watt incandescent lamp three inflated Foley catheters k. A.
thermometer Biopsy forceps general anesthetic
vibrator transanal Kocher clamp Local anesthesia
Bowling bottle (bottle in the shape of a pin) Obstetric forceps general anesthetic
Perfume bottle manually Spinal anesthesia
Piece of wood manually general anesthetic
Toothbrush case inflated Fogarty catheter k. A.
Oven glove Forceps after anal dilation general anesthetic
Drainpipe Obstetric forceps general anesthetic
Boule ball Electromagnet general anesthetic
carrot Myoma lifter k. A.
Vitreous Suction cup Spinal anesthesia
Rubber ball manual extraction with anal dilation general anesthetic
Wooden stick two-handed anal dilation Spinal anesthesia
bottle manually after anal dilation general anesthetic
Dildo Myoma lifter k. A.
Lightbulb abdominal compression Spinal anesthesia

Data after

APC = argon plasma coagulation
k. A. = not specified

Possible consequences of a foreign body not being removed

If the foreign body is so large that no stool from the colon can pass through it, a mechanical intestinal obstruction (ileus) occurs. The stretching of the rectum and the resulting disruption of the intestinal peristalsis also promote ileus.

The foreign body can destroy the intestinal wall through inflammatory processes ( erosion ). This may, depending on the location of the perforation, a muddy peritonitis or retroperitoneal abscess formation (formation of an abscess behind the peritoneum lead).

Smaller foreign bodies that injure the intestinal wall but do not perforate it can become trapped in a foreign body granuloma . They may then remain in the rectum for years as a pseudotumor without any consequences.

Complications

The most common - but generally rare - complication is perforation of the rectum by the foreign body itself or by the measures taken to remove it. Diagnosed perforations are usually operated on immediately in the clinic. To do this, the patient's abdomen is opened (laparotomy) and the perforated area is either cut out or treated with a primary suture . Patients are usually antibiotics administered to infections to suppress. In order to protect the sutures, a temporary relieving colostomy, i.e. a temporary artificial anus, is usually necessary. The relieving colostomy is shifted back after a contrast agent injected as an enema has demonstrated that the previously perforated area of ​​the rectum has completely healed. This typically takes three to six months from the time of the operation. According to a study, the average hospital stay after a perforation is 19 days.

Some deaths from foreign bodies in the anus and rectum have been described in the literature, but are generally very rare. Deaths are assigned to the group of autoerotic suicide accidents . For example, a 75-year-old patient died from a perforation in his rectum made by a mentally ill patient with a walking stick. Another middle-aged patient died of a perforation in his rectum by a vibrator. The perforation was sutured and the patient was given intensive care, but as a result of the trauma he developed Acute Respiratory Distress Syndrome (ARDS) and Systemic Inflammatory Response Syndrome (SIRS), which ultimately led to multiple organ failure . A death is also described after perforation of the rectum by a shoehorn . After a surgical procedure, the rectum should be spared until it is completely healed. A 54-year-old, the previously twice a rectal foreign body be removed surgically had (cucumber and parsnips ), died of peritonitis (peritonitis) since moving to the previous operation - introduced two apples into his rectum - and before complete healing of the wound .

Rectal foreign bodies by ingestion

The reverse route of a foreign body - oral ingestion and passage through the entire gastrointestinal tract into the rectum - is very often followed, but is rarely clinically relevant. Other constrictions such as the esophagus , stomach mouth , pylorus and ileocecal valve usually lead to problems in other organs if foreign bodies are large enough. However, some foreign bodies pass the bottlenecks on the way to the rectum and can lead to clinically relevant problems in the rectum. These include toothpicks and bones, for example. Especially with bones, for example of chickens, there is a risk of perforation of the intestine. Almost half of all perforations are caused by bones.

Plant-based foods, especially seeds such as popcorn or watermelon , sunflower and pumpkin seeds , can also aggregate in the colon to form bezoars that are too large for normal anal passage and can thus become clinically relevant as rectal foreign bodies. This type of rectal foreign body occurs primarily in children and is of particular clinical importance in North Africa and the Middle East , where such kernels are an important part of the diet. In rare cases, plant seeds from such bezoars can germinate in the colon and / or rectum and also lead to blockages in this way.

Rectal foreign bodies in veterinary medicine

Rectal foreign bodies are rare in veterinary medicine . A foreign body passage through the entire intestine and then remaining in the rectum is - analogous to the situation in humans - a rather rare occurrence. Bezoars made of various materials can also be found in animals , and they can get into the rectum and cause problems there. Atypical rectal foreign bodies in animals of both sexes can also occur as a result of sexually and / or sadistically motivated abuse.

Ig Nobel Prize

The Ig Nobel Prize was awarded to David B. Busch and James R. Starling from Madison (Wisconsin) in 1995 for their article Rectal foreign bodies: Case Reports and a Comprehensive Review of the World's Literature (German: "Rectal foreign bodies: case studies and a comprehensive overview of the worldwide literature ”) (see list of winners of the Ig Nobel Prize ).

further reading

Reference books

Review article

Original research

Web links

Commons : Foreign bodies in the anus and rectum  - collection of images, videos and audio files

Individual evidence

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