• The free public passage of flatus.
• In doing so he repealed an earlier decree permitting this activity, made by the Emperor Claudius.

These presentations are potentially challenging for a number of reasons:

• patient factors —
  embarrassment, unreliable history, psychiatric illness
• possible sexual assault
• body packers require special consideration due to forensic issues and potential toxicity of package rupture
• potential harm to patient and staff if the object is dangerous, e.g. sharp objects
• procedural sedation and local/ regional anesthesia is usually required for attempted removal in the ED
• life threats are rare but possible, e.g. perforation

Patients need to be treated with the utmost sensitivity, no matter how strange and seemingly comical the situation is. Patients may have coexistent mental illness, may have been subjected to terrible assaults or may just have had an unfortunate mishap!

Our role is to help… not judge.

History

• type of foreign body
• delay since foreign body placement
• factors leading to the presence of the foreign body
  

1. sexual —
   autoerotic (most common type of rectal foreign body presentation)
   assault
2. non-sexual —
   body packing or stuffing of drugs
   psychiatric illness (present in about a third of cases)
   intellectual disability
   ingestion, e.g. toothpicks, bones, plastic objects
   iatrogenic, e.g. retained rectal thermometer

• previous extrication attempts
• previous foreign body presentations and treatments employed
• complications —
  pain, impaction, bowel obstruction, perforation, urinary retention, gastrointestinal hemorrhage, package rupture in body packers
• presence of other injuries if assault/ non-accidental injury suspected
• past medical history —
  comorbidities, previous surgery, medications, allergies
• social history

Examination

• assess for life threats —
  use an ABC approach and assess vital signs
  rule out perforation as a priority (suspect if  hypotension, tachycardia, peritonism and/or fever)
  look for evidence of gastrointestinal hemorrhage, package rupture in a body packer and life-threatening associated injuries if suspected assault
• abdominal examination —
  look for palpable mass, urinary retention, obstruction and perforation/ peritonism
  consider other causes of abdominal pain and perform genital examination
  
• rectal examination —
  assess for a palpable foreign body, for hemorrhage and for anal tone
  beware of potentially hazardous foreign bodies (e.g. sharp object)
• assess for associated injuries (head-to-toe exam)
• assess for toxidromes, e.g. heroin or cocaine toxicity in a body packer
• mental status examination

Laboratory tests are usually of limited utility in this setting

Bedside

• blood glucose and VBG —
  e.g. suspected obstruction or perforation, vomiting
• urine bHCG if female
• anoscopy, e.g. with small vaginal speculum

Laboratory

• FBC, UEC, LFTs, lipase —
  consider the differential diagnosis of abdominal pain
• Group and Hold —
  if significant hemorrhage

Imaging

• AXR and erect CXR —
  identify type and location of foreign body; stable patients with suspected complications such as obstruction or perforation
• CT abdomen —
  if body packing or foreign body is suspected but not visuallised on XR; stable patients with suspected complications such as obstruction or perforation

A circular radio-opaque object is present in the rectum. Complications cannot be excluded based on this image alone.

Photo by MHorama (click image for source)

Immediate management

• manage ABCs; seek and treat life threats

Specific management

• consider removal of the foreign body in the ED if it is:

1. not a dangerous object
   (e.g. light bulbs have high risk of breakage)
2. palpable on PR exam
3. distal to the sigmoid on AXR
   (foreign bodies proximal to the sigmoid tend to abut the sacrum preventing removal)

• provide adequate analgesia and sedation —
  e.g. titrated morphine and midazolam
  Ideally ensure the patient remains awake enough to help ‘push’
• provide local/ regional anesthesia —
  Perform a perianal block, e.g. circumferential subcutaneous infiltration around the anus using lignocaine with adrenaline, followed by a deeper intersphincteric block.
  A pudendal nerve block can also be performed.

• attempt foreign body removal using a stepwise approach and set a 10-20 minute limit on the duration of  attempted removal in the ED —
  Position the patient, e.g. lithotomy position; alternatives include: lateral decubitus, prone, or knee-chest position
  First attempt removal by pushing on the abdomen to propel the foreign body distally while pulling on the object with the fingers of your other hand inside the patient’s rectum. Forceps or a clamp may also be used.
  If unsuccessful, consider passing a foley catheter past the foreign body to help break the suction around the object (air can be insufflated proximal to the foreign body via the foley). Then inflate the balloon and withdraw to help dislodge the object.

• if still unsuccessful, obtain a surgical consult and consider the following options:

1. patient repositioning
2. sigmoidoscopy
3. vacuum devices
4. per rectal removal under general anesthesia
5. use of obstetric forceps
6. endoscopy-assisted removal
7. laparoscopy-assisted removal
8. laparotomy

• seek and treat complications —
  e.g. perforation, obstruction, hemorrhage, urinary retention, anal tone/ sphincter dysfunction, toxicity from package rupture in body packers, and medication adverse reactions (e.g. allergy, effects of procedural sedation)
• aftercare —
  consider performing anoscopy/ sigmoidoscopy following removal of a rectal foreign body to check for evidence of trauma

Supportive care and monitoring

• may include —
  IV hydration, analgesia, sedation, IDC, NGT if obstruction
• psychosocial support
• consider observation for a few hours post-removal and a repeat abdominal XR to check for evidence of perforation

Disposition

• see Q7 below

In the case of this billiard ball, passing a foley catheter beyond the object to release suction may be necessary. Gripping the ball may also be difficult. Vacuum devices or more invasive measures may be required.

Regarding the perianal block —
Rob Orman of ERCAST fame is the man I turn to when confronted with an anus problem, given his considerable experience with these issues … He describes the perianal block as an ‘auricular block of anus’ and finds it is usually successful. Infiltrate subcutaneously, pointing away from the rectum, by making 4 linear infiltrations in the shape of a box around the anus. Easy, eh. But, don’t try it at home kids…

Rectal regrets —
Check out this fantastic short ‘procedurette video’ by Whit Fisher which shows how to create a suction device out of a neonatal suction bulb and how to break suction by passing a foley catheter:

http://www.youtube.com/watch?v=t8GGQWMu004

Disposition depends on the nature of the foreign body, the success of the removal attempts, the presence of complications, and the patient’s mental state.

Disposition

• Successful removal in the ED —
  consider need for review by mental health team, sexual assault team and the social work team.
  provide written and verbal patient advice
  contact GP (phone/ fax/ letter) and arrange follow up, ideally the next day
  ensure careful documentation (especially if forensic issues)

• Body packers —
  consult toxicology and general surgery
  admit for consideration of whole bowel irrigation +/- endoscopic/ surgical removal

• Foreign body unable to be removed in the ED —
  admit under general surgery
  keep NBM pending possible transfer to the operating theatre

Faecaloma: (Also known as fecoma, faecoma, fecaloma)

• An accumulation of inspissated faeces in the distal (sigmoid) colon or rectum.
• The mass of feaces is much harder than a fecal impactation due to coprostasis.
• The composition of the mass is heterogeneous. Faecalomas usually consist of faecal matter and intestinal debris formed in a laminated fashion due to deposits of calcium soaps in layers.

Aetiology

• Damage to the autonomic nervous system in the large bowel associated with
  • Chagas disease (inflammatory and neoplastic)
  • Hirschprung’s disease
• Psychiatric patients
• Patients suffering with chronic constipation and cathartic bowel syndrome

Clinical Presentation

• Symptoms of fecaloma are usually nonspecific.
• Most patients are adults and present with symptoms of
  • Overflow diarrhoea
  • Constipation
  • Weight loss
  • Vague abdominal discomfort after meals.
• Clinical examination can give the appearance of an abdominal tumour

Complications

• Bowel obstruction and ulceration
• Bowel perforation (stercoral perforation)
• Hydronephrosis
• Rectosigmoid Megacolon
• Death

The same patient had an erect abdominal X-ray taken at initial presentation

Treatment

• Most cases of faecaloma are treated conservatively with laxatives and enemas
• Digital evacuation or catheter disimpaction may be required
• Endoscopic removal has also been described [Reference]
• In severe and unremitting cases – surgery is required to prevent significant complcations

In this case a trial of conservative measures failed, and surgical intervention was required....

Summary:

• Fecaloma should be considered in the differential diagnosis of any patient with history of chronic constipation and abdominal mass.
• Diagnosis is made form the clinical and radiologic features.
• Initial treatment is conservative. Rarely laparotomy is required to remove the mass.

The history provided is concerning as it is consistent with the ingestion of a dangerous corrosive agent. For instance, solid preparations of sodium hydroxide (in combination with other agents) are commonly sold as drain cleaning products.

As with any risk assessment it is important to go to great lengths to determine the nature of the ingested substance. This may necessitate searching the home for drain cleaning products if the child’s father is unsure what the crystals were. If the product is known but you are still unsure of the contents then liaise with your regional Poison Information Centre. PIC staff  can rapidly obtain the relevant information by searching their databases and, if necessary, by accessing information from the product’s manufacturer. If the substance cannot be identified, then assume the most likely ‘worst case scenario’, track the patients clinical progress and keep an open mind.

Remember the key components of a risk assessment:

• agent(s)
  (including pH for corrosive agents)
• dose(s)
  (including concentration and volume for corrosive agents)
• time(s) of ingestion
• patient factors
  (e.g. comorbidities)
• clinical progress
  (What is the patient like now? Does the story fit?)

Try to determine if the pellets were ingested or spat out. If the pellets were spat out corrosive injury may be limited to the mouth and lips. Determining what signs and symptoms the child has now will help refine the risk assessment.

However, two key tips to remember when assessing patient’s with corrosive injuries are:

• The absence of lip or oral burns does not exclude significant gastrosophageal burns.
• Signs and symptoms correlate poorly with the extent of gastrointestinal injury

Most corrosive agents cause direct chemical injury. Some (see Q4) may also cause severe systemic toxicity.

The extent of direct chemical injury depends on:

• pH
• concentration
• volume ingested

Acidic agents cause protein denaturation resulting in coagulative necrosis. Alkaline agents are more dangerous as they cause liquefactive necrosis resulting in deep and progressive mucosal burns. Other corrosive agents may have reducing, oxidising, denaturing or defatting actions.

Commonly available corrosive agents include:

• Sodium hydroxide — detergents, drain and oven cleaners, button batteries
• Sodium hypochlorite — bleaches and household cleaners (unintentional ingestion in children is generally benign, dilute solutions less than 150 mL do not cause significant corrosive injury)
• Ammonia — metal and jewelery cleaners, anti-rust products
• Hydrochloric acid — metal cleaners
• Sulfuric acid — drain cleaners, car batteries
• Button batteries — injury results from leakage of alkali, local electrical current discharge and direct pressure necrosis

Examples of corrosive agents that can cause severe systemic toxicity include:

• glyphosate (toxicity may be due to the herbicide’s polyoxyethyleneamine surfactant) — metabolic acidosis, shock, multi-organ dysfunction
• hydrofluoric acid — hypocalcemia
• mercuric chloride (inorganic mercury salts) — renal failure, shock
• oxalic acid — hypocalcemia, renal failure
• paraquat — pulmonary fibrosis, multi-organ dysfunction and shock
• phenol — coma, seizures, hepatotoxicity, renal failure
• phosphorus — hepatotoxicity, renal failure
• picric acid — renal failure
• potassium permangante — methemoglobinemia, multi-organ failure
• silver nitrate — methemoglobinemia
• tannic acid — hepatotoxicity

Remember (at the risk of excessive repetition…):

• The absence of lip or oral burns does not exclude significant gastrosophageal burns
• Signs and symptoms correlate poorly with the extent of gastrointestinal injury

Corrosive ingestion may result in immediate symptoms of injury to the gastrointestinal tract:

• mouth and throat pain
• drooling
• odynophagia
• vomiting
• abdominal pain

Upper airway injury is the most important immediate life-threat. Laryngeal injury and edema presents with:

• progressive stridor
• hoarseness
• respiratory distress

The  endoscopic findings of corrosive injuries are graded as follows:

• Grade 0 — normal
• Grade I — mucosal edema and hyperemia
• Grade IIA — superficial ulcers, bleeding and exudates
• Grade IIB — deep focal or circumferential ulcers
• Grade IIIA — focal necrosis
• Grade IIIB — extensive necrosis

Complications include:

• Perforation

• Esophageal perforation and mediastinitis (chest pain, dyspnea, fever, subcutaneous edema)
• perforation of the stomach or small intestine resulting in peritonitis
• septic shock and multiple organ dysfunction syndrome (MODS)

• Esophageal strictures — occurs in 30% of patients with Grade IIB or II injury on endoscopy
• Esophageal carcinoma — may occur over 40 years after a Grade II or III corrosive injury

This boy’s father did the right thing:

Rinse the mouth with water as an immediate first aid measure.

Important things NOT to do include:

• do not induce vomiting
• do not administer oral fluids
• do not administer activated charcoal
• do not attempt pH neutralisiation
• do not perform gastric lavage or insert an nasogastric tube (until endoscopy is performed)

Use the Resus-RSI-DEAD approach.

Resuscitation:

Manage the patient in an area equipped for resuscitation with appropriately skilled staff.

Assess for life-threats – is there evidence of airway compromise? (see Q5)

• airway compromise from oedema may progress rapidly
• prepare to intubate early at the first signs of compromise, otherwise the edema may progress and a surgical airway become the only available option.
• Call for expert help (e.g. the most senior anesthetist available, with ENT back-up) and consider intubating while the patient is spontaneous breathing (e.g. gas induction in the operating theatre or an awake fiber-optic intubation in a cooperative patient).

Risk assessment (see Q1) — assess for evidence of corrosive injury (see Q5):

• symptoms and signs of gastrointestinal injury
• remember to check for corrosive injuries to other parts of the body such as the skin and eyes.

Supportive care and monitoring (including adequate analgesia)

• keep the patient NBM if symptomatic, pending endoscopic assessment.
• Do not insert a nasogastric tube until cleared of gastrointestinal injury (e.g. endoscopy)

Investigations, decontamination, enhanced elimination and antidotes:

Perform a chest x-ray and abdominal x-ray for evidence of perforation if the child has suggestive symptoms or signs

No further decontamination is needed

Enhanced elimination is not useful

No antidotes are available

Disposition is determined by the risk assessment and the child’s clinical progress.

The possibilities are:

• The child is asymptomatic at 4 hours post-ingestion, so a trial of oral fluids is performed. If this is tolerated well the child can be discharged (avoid discharging a child at night). Some experts advocate endoscopy following corrosive ingestion even in the asymptomatic patient.
• The child is symptomatic (e.g. throat pain, drooling, pain on attempting to swallow his own saliva, or has vomiting or abdominal pain). The child is kept NBM and admitted for observation and an endoscopy within 24 hours.
• The child has airway compromise. Take measures to secure the airway and arrange ICU admission.
• The child has evidence of gastrointestinal perforation, sepsis or hemodynamic instability. Arrange for an urgent surgical assessment and ICU admission.

No — unless there is evidence of gastrointestinal perforation, which may result in mediastinitis or peritonitis and subsequent severe sepsis.

The use of corticosteroids for the treatment of gastrointestinal corrosive injuries from alkaline agents is controversial. However there is no evidence that corticosteroids are effective in preventing esophageal stricture formation. Furthermore, there are concerns that corticosteroids may actually increase mortality in Grade III injuries, increase the risk of infection or conceal the symptoms and signs of perforation.