Pulling it out of your posterior

One of the stranger aspects of being a general surgeon or a colorectal surgeon can be summed up by this abdominal X-ray (click on the picture for a bigger image):

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Yep. From time to time, every general surgeon will be called upon to pull something out of someone’s ass. It’s not super common, but common enough that pretty much every general surgeon’s seen a few. In the case above, it would appear that the offending object is an aerosol can. I know what you’re probably thinking first: Why? I also know what you’re thinking next: How? (As in: How on earth did he get that up there?)

Believe me, you don’t want to know. Well, actually, when I encountered these patients I sort of did (and you probably would too), but respect for a patient’s dignity and the need not to embarrass him any more than the already embarrassing situation requires, no matter how much sleep deprivation may have compromised my self-control, prevented me from inquiring too much. (Remember, I trained back in the days of giants, so to speak, before the days of the 80 hour workweek limitations, when it was not at all uncommon for me to be at the hospital well over 110 hours a week. Also remember that these sorts of patients tend to come to the E.R. in the middle of the night, both because not a few of them tend to be drunk and also possibly because they are embarrassed.) After all, part of being a doctor is to try to suppress your curiosity and stick to a “just the facts, Ma’m,” kind of attitude. Such an attitude serves a surgeon well in these situations. Although it’s highly unlikely that this was the case for the aerosol can, sometimes these objects end up getting to the rectum by way of the stomach, when objects are swallowed.

I personally haven’t had to retrieve a rectal foreign body from a patient since my surgical residency (there’s not much call for such skills in surgical oncology or breast surgery), but I fished my share of strange things out of rectums during the five clinical years of my residency. I can’t say that I’ve ever had to deal with an aerosol can, but one case back in Cleveland that I’ll never forget involved a middle aged man who had placed a flaming pink salt shaker from a party center known as Vel’s on the Circle (which, ironically enough, was apparently sold to the Cleveland Clinic a number of years ago). Of course, I didn’t know that that’s what it was until we had retrieved it, but I’ll never forget delivering a large pink, plastic object that we had trouble identifying while we were trying to extract it, but when it suddenly popped free the word “Vel’s” was engraved in my mind in a way that I’m sure the owners of Vel’s on the Circle had certainly never intended.

Of course, this guy was lucky. Although we did have to take him to the operating room in order to get adequate anaesthesia and relaxation of the anal sphincter with to allow extraction of the salt shaker, he escaped harm. What people don’t seem to realize is just how much damage they can do to themselves by sticking objects up their posteriors.

Another rather odd case I recall was a guy who showed up at the E.R. of University Hospitals with the chief complaint that he had shoved several golf balls up there and that he couldn’t get them out. He admitted to having been drunk at the time. He apparently passed out after his attempt to get closer to Tiger Woods, except that this occurred a bit before Tiger Woods had become famous. In any case, after waking up, he remembered what he had done and couldn’t remove them himself–or, for that matter, even find evidence that they were “up there.” We sent him for an X-ray, as you would expect, as that’s frequently one of the easiest ways to figure out what’s up there, assuming the object is something that shows up on X-ray. I even remember that we had a bit of an argument between attendings over whether golf balls were even radioopaque. One settled the argument by referring to a radiology attending who had a bit of a habit of X-raying various objects, who had assured him that golf balls showed up on X-ray.

There were no golf balls seen on the X-ray.

Given the small size of golf balls (come on, what adult hasn’t produced a masterpiece of bathroom creation larger than a golf ball), we ultimately let him go home, unable to find any evidence of a golf ball in the rectum and figuring that he probably either eliminated them himself or never put anything up there in the first place. If he did “dislodge” them himself, I hope he washed them before using them.

If there is no evidence of perforation or obstruction, one of the cardinal rules of dealing with this clinical problem is to decide early whether the foreign body can be extracted in the E.R. or whether the patient needs a visit to the operating room, with the threshold for taking the patient to the O.R. being set quite low. Serious damage can be done to the anal sphincter resulting in permanent incontinence from an ill-advised persistence in trying to use force to muscle out a foreign body that is stuck. Such attempts can also tear the rectum, leading to an abscess. The tools at a surgeon’s disposal include:

The patient was taken to operating room within 12 hours of presentation, with consent for colostomy. Under general anaesthesia in the lithotomy position, dilatation of anal sphincter was performed and per rectum retrieval successful.

These patients typically have a delayed presentation to the emergency department because of embarrassment and after multiple attempts at self removal. Respect for their privacy is a key factor in the patient’s care plan. ED physicians need to decide if removal of foreign body can be performed in the emergency department or surgical team to be notified. Operating room procedures include anal dilatation under GA, transrectal manipulation, bimanual palpation if necessary and withdrawal of foreign body. Laparotomy or laparoscopy are occasionally necessary.

This study gives an idea of the potential complications and points out an important point, namely that the patient may not always tell you that they stuck something up there and that the doctor may have to figure it:

Objective The discovery of foreign bodies (FB) in the rectum is an infrequent clinical problem. Most commonly, FB are introduced through the anal passage or reach the rectum after oral ingestion. We describe our experience in the diagnosis and treatment of FB retained in the rectum.

Method From 1997 to 2004, data were collected prospectively in 30 patients (20 men and 10 women; median age 42.5 years). Extraction method, size and type of object, and postextraction evolution were reviewed.

Results The FB was introduced anally in 16 cases and by oral ingestion in 14. Principal associated factors were: mental disorder in 11, penitentiary confinement in two, and drug and alcohol intake in two. Recent sexual activity had taken place in 14 cases. The size and nature of the FB were varied. The most frequent symptom was constipation with or without pelvic or anal discomfort (n = 23, 77%). Treatment consisted of spontaneous ejection (n = 2), digital extraction with or without enemas (n = 10), digital extraction under local/regional anaesthesia after fragmentation (n = 11) and regional exploratory laparotomy under general anaesthesia (n = 7). Grade I rectal trauma was the most common (n = 23, 77%). Six patients required colostomy. Four patients (13.5%) suffered complications and none died. Only 17 patients were hospitalized, with a mean stay of 6 days. All patients recovered without sequelae.

Conclusion The diagnosis of rectal FB should be suspected when faced with low pelvic or perianal abdominal pain and/or rectal haemorrhage within the context of an unconvincing story in patients without a history of recent instrumental rectal exploration for therapeutic or diagnostic purposes. Because of potential complications, FB in the rectum should be considered a serious condition that must be treated without delay.

In other words, 6/30 patients, or 20%, required colostomy. Albeit uncommon and fairly straightforward to manage if recognized, foreign bodies lodged in the rectum are a serious and potentially even lethal if diagnosis is delayed long enough. All jokes aside, they’re no laughing matter.