Rectal Foreign Bodies and Other “Weapons of Ass Destruction” II: Return of the Red Eye Michael Su MD CCFP(EM) Emergency Medicine Grand Rounds January 29 th, 2009
Accreditations/special thanks to: • • • Dr. Eric Grafstein, MD, FRCP Dr. Rick Walker, MD FRCP Ms. Monica Fredborg, RTR
• The following hairstyle is associated with: • • A) rectal foreign bodies B) a C) a + b D) all of the above
Objectives • • • Review Epidemiology of Foreign Bodies Structural Issues History and physical exam Review Management Issues Around Removal Special cases Complications Legal implications Skill-testing session: “What am I”
Case 1: • A 34 year old male presents to the ED with a vibrator lodged firmly in his rectum. He tells you that he tried to get it out, his girlfriend tried to get it out, and that everybody there tried to get it out. • On exam he is in no distress, vitals are stable. Abdominal exam is unremarkable. On rectal exam you can just feel the tip of the vibrator. You think this might be retrievable in the ED with procedural sedation. • As the young female respiratory therapist leaves the room for equipment, the patient says to you that he should probably scratch her off his “someone I’d like to date list”, and he then informs you that he had Kolbasa sausage the night before. As you reflect on the case you wonder why they didn’t teach you about this in medical school, and that you believe there is still time to reassign the patient to Dr. Abbi on REDIS…
Search Methodology • Medline 1966 - current • Wolters Kluwer | Ovid. SP
Results of search • • • 240 articles found 175 identified as possibly relevant Abstracts reviewed (large number of case studies, no RCT identified) bibliographies Expert consultation with ….
Google search • • “weapons of ass destruction” 329 000 items retrieved in 0. 2 seconds
Epidemiology
Incidence and prevalence • Mostly case series, with ranges of 8 to 101 cases on average over 5 year periods, • • • Calgary data, St. Paul’s data • • Incidence is increasing • Singaporewella RM et al. Use of Endoscopic Snare to Extract a Large Rectosigmoid Foreign Body with Review of Literature. Surg Laparosc Endoxc Percutan Tech 2007; 17: 145 -148 male predominate 35: 1 ? Bimodal distribution (30’s and 60’s) although all ages included, all data based on very small sample sizes Presentation: typically 6 -48 hours after transanal insertion; 48 hours-3 months after orally ingested rectal FB
Incidence and prevalence • Up. To. Date Online 16. 3, 2009 http: //www. uptodate. com
Maybe we should ask the registrants at this conference…
Calgary Health Region 2003 -2008
Rectal Foreign Bodies at SPH N = 28
Anatomy
Anatomy Netter, Atlas of Human Anatomy, 1989
Anatomy Netter, Atlas of Human Anatomy, 1989
Anatomical Considerations • • • Anal canal 4 cm long, rectum 12 cm long beginning at 3 rd sacral vertebra Rectum covered with peritoneum for first two-thirds of its course Arterial and venous supply of rectum: superior, middle, and inferior hemorrhoidal arteries and veins Lymphatics: inguinal lymph nodes, external iliac or common iliac lymph nodes Anal canal lined by stratified epithelium, highly sensitive to pain; rectum lined by mucosa, insensitive to pain • Once above levator ani, muscles and conical shape of the pelvis cause FB’s to rise above the pelvic brim; FB usually becomes impacted at the sacral hollow where rectum forms a sharp anteriorposterior curve • Irizarry E et al: Rectal sexual trauma including foreign bodies. International Journal of STD & AIDS; 7: 166 -169 Brenner BE, Simon RR: Anorectal emergencies. Ann Emerg Med 12: 367 -376, June 1983 •
Physiological Considerations • • • 4 groups of muscles involved in anorectal physiology: 1. external sphincter: striated muscle, voluntary control, prevents defecation even when urge present 2. internal sphincter: prevents stool from entering anus, maintains stool in rectum causing rectal ampulla to dilate 3. puborectalis: reflexively intitiates defecation in a propulsive wave, provided external sphincter relaxed 4. levator ani: finishes expulsion of stool Brenner BE, Simon RR: Anorectal emergencies. Ann Emerg Med 12: 367 -376, June 1983
Circumstances of Rectal Foreign Body Introduction • • • 1. diagnostic or therapeutic: thermometer, barium, rectal tube, disposable enema tip, irrigation catheters 2. self-administered treatment to alleviate symptoms of anorectal disease eg. Insertion of broomstick to relieve itching or to reduce prolapsed hemorrhoids 3. criminal assault 4. autoeroticism 5. accidental introduction Eftaiha M et al: Principles of Management of Colorectal Foreign Bodies. Arch Surg 112: 691 -695, 1977
Classification
Classification • • Many different characteristics (shape, composition, surface contour, orientation) influence ultimate method of removal Initial approach: 1. low-lying: palpable in the rectal ampulla 2. high-lying: in or proximal to the rectosigmoid junction
Classification of FB • “Only limitation of objects used is the capacity of the rectum to accommodate them” • Busch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the World’s Literature. Surgery 1986; 100(3): 512 -9
Classes of Foreign Bodies Glass or ceramic Wooden Misc tools Inflated device Bottle or jar Axe handle Candle Balloon Bottle with attached rope Stick or broom Flashlight handle Iron rod Miscellaneous Pen Glass or cup Light bulb Kitchen Devices Rubber tube Dull knife Screwdriver Ice pick Toothbrush Banana Knife sharpener Wire spring Carrot Mortar & pestle Tube Food Apple Parsnip Plantain (with condom) Potatoe Condom Bicycle inner tube Balls Baseball Tennis ball Bocce ball Misc Containers Candlebox Cucumber Onion Balloon attached to cyl Spatula Snuffbox (plastic) Busch DB et al. Rectal Foreign Bodies: Case • Reports and a Comprehensive Review of the World’s Baby powder can Spoon Literature. Surgery 1986; 100(3): 512 -9 Tin cup
. . . Miscellaneous Bottle cap Cattle horn Frozen pigs tail Kangaroo tumor Plastic rod Stone Toothbrush holder Toothbrush package Whip handle Gerbil • Busch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the World’s Literature. Surgery 1986; 100(3): 512 -9
. . . Collections 2 glass tubes 72 -1/2 Jeweller’s saw Oil can with potatoe stopper Piece of wood, and peanut Umbrella handle and enema tubing 2 Glasses Phosphorous match ends (homicide) 402 stones Toolbox 2 bars soap Beer glass and preserving pot Lemon and cold cream jar 2 apples • Busch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the World’s Literature. Surgery 1986; 100(3): 512 -9
Age Distribution • Busch DB et al. Rectal Foreign Bodies: Case Reports and a Comprehensive Review of the World’s Literature. Surgery 1986; 100(3): 512 -9
World Records
World Records • What is the longest documented rectal FB retrieved? : • 14 inch piece of sandfilled bicycle inner tubing (close • • second 30 cm x 2. 5 cm garden hose (colonscope passed through lumen of FB with hose) Obrador A et al. Colonoscopic Removal of a Long Piece of Garden Hose. Gastrointestinal Endoscopy 1988; 34(3): 286 -7
World Records • What is the widest documented rectal FB retrieved? • • • . 85 kg stone, oval in shape, 23. 3 cm in circumference, 12 x 8. 6 x 8. 8 cm Removed with bone forceps Sachdev YV et al. An Unusual Foreign Body in the Rectum. Diseases of the Colon and Rectum 1967. 10; 3: 220 -221
World Records • What is the best travelled rectal FB on record? • Case Report: • bachelor, mid 60’s presented with severe anal pain after vigorous extracurricular activities the night before. • Freely mobile palpable abdominal mass, painful rectal exam • Referred for surgical opinion, declined as patient stated he was on a world tour • Returned 6 months later for FB removal, 20 cm x 2. 5 cm vibrator removed • • Longest recorded in situ FB case recorded Also best travelled • Buzzard AJ et al. A Long-Standing, Much Travelled Rectal Foreign Body. Med. J. Aust. , 1979, 1: 600
Approach
Management of Rectal Foreign Bodies • Singaporewella RM et al. Use of Endoscopic Snare to Extract a Large Rectosigmoid Foreign Body with Review of Literature. Surg Laparosc Endoxc Percutan Tech 2007; 17: 145 -148
History • • • “How did it happen” Description of the circumstances surrounding the injury is usually suspicious Usually attributed to some type of accident or therapeutic misadventure ~1/3 admit to transanal insertion, 2/3 complain of vague anal pain Always be attuned to the possibility of physical abuse Boon-Swee Ooi et al. Management of Anorectal Foreign Bodies: A Cause of Obscure Anal Pain. Aust. N. Z. J. Surg. (1998)68, 852 -855
History • Case 1: the garden story • Case 2: baseball in rectum • 49 y/o male, presented with urinary retention and round firm object firmly lodged in rectum • He and his partner had celebrated a World Series victory of the Oakland Athletics by placing a baseball into his rectum because “he was oversexed” • Case 3: vaseline jar in rectum • 57 y/o male, massaging his “rear end” with a jar of petroleum jelly to relieve a bothersome itch • He “coughed and sneezed at the same time”, caused the rectum to relax and the jar to slip in as he sat down at the edge of the bed • Mc. Donald PT et al. An Unusual Foreign Body in the Rectum-A Baseball: Report of a Case. Dis Colon Rectum 1977; 20: 1 56 -7
History: A case of atypical chest pain • • • Case: 71 y/o male, admitted to CCU with chest pain radiating to epigastrium, associated with vomiting, no abd pain Rectal FB risk factor on hx: admitted for urethral FB extraction 2 years previously • Eventual hx came out, FB removed in OR under spinal • 48 hours, intra-abdominal sepsis, peritonitis • Perforated sigmoid colon, Hartmann’s procedure, discharged 6 weeks later Dale OT et al. Tube abuse: a rectal foreign body presenting as chest pain. ANZ Journal of Surgery 2007; 77(12): 1131 -2
History: A case of atypical chest pain • Dale OT et al. Tube abuse: a rectal foreign body presenting as chest pain. ANZ Journal of Surgery 2007; 77(12): 1131 -2
Physical Exam • Focus on abdomen (to exclude perforation), inspection of anus, and careful digital exam • • • Unusual avoidance of pelvic/anal exams Rectal/vaginal lacerations, bleeding, scars Anal fissures, fistulas Mucosal irritation (secondary to soaps, shampoos used as lubricants) Foul-smelling anal or vaginal discharge Localized discomfort to anus, vagina • The “vibrating umbilicus” sign (Mike Betzner) • • • 25 y/o male, loss of vibrator, deep central abdominal ache, vibrating umbilicus, and a gentle hum Attempt to deliver the vibrator too painful but manipulation resulted in mechanism being turned off, with resolution of pain and vibrations Jackson D et al. Vibrating Umbilicus. BMJ. 2/5869 780.
Laboratory & Imaging
Investigations: ECG • Hammond EJ et al. , An Unusual ECG. Anaesthesia, 2001, 56(4): 402.
Anal Fibrillation
Role of Imaging • • • Define the foreign body Free air? Is there only one? Timing? To provide content for emergency medicine grand rounds
Radiographic Detection of Foreign Bodies • Classification • 1. highly radiopaque: high physical density, low photographic density on radiograph (bullet fragments, surgical clips, orthopedic hardware • 2. slightly radiopaque: physical density slightly higher than body tissues (e. g. glass, aluminum, chicken bones, some plastics) • 3. body density: no visible difference in photographic density between these materials and body tissue (e. g. thorns, some plastics, and wood in situ for more than 48 hrs) • 4. radiolucent: lower physical density than body tissue, produce a greater photographic density than body tissue (e. g. wood within a short period of injury, some plastic materials, materials containing air) • Radiopacity proportional to density or weight per unit volume of the material examined Denser material absorbs more photons • • Fodor J et al. The Radiographic Detection of Foreign Bodies. Radiological Technology 1983. 54/5: 361 -70
Radiolucent Foreign Body Objects Lee KF et al. Radioluscent foreign body visible on plain radiography. Can J Surg 2008. 51; 3: 87 -88
Radiolucent Foreign Body Objects Lee KF et al. Radioluscent foreign body visible on plain radiography. Can J Surg 2008. 51; 3: 87 -88
Radiographic Detection of Foreign Bodies • • • Misconceptions: glass, aluminum, wood Glass: all glass normally encountered radiopaque compared to body tissue Aluminum: metal of low physical density, may be very difficult to detect radiographically Wood: dry wood lower physical density than body tissues, within 24 -48 hours becomes water logged and equivalent in density to body tissue Fodor J et al. The Radiographic Detection of Foreign Bodies. Radiological Technology 1983. 54/5: 361 -70
Radiographic Detection of Foreign Bodies • • • Contrast studies: foreign bodies present as filling defects in the contrast-filled structure. gastrograffin enema Computed Tomography: can detect differences in tissue density as low as 0. 5% Ultrasound
Removal
ED Principles of Removal • • • Exclude perforation Object must be able to be removed transanally High-lying bodies must be convertible to low-lying bodies Planned approach to removal; equipment for position conversion and extraction at bedside No ED removal if FB fragile and there is risk of bowel damage if it fragments Wigle RL. Emergency Department Management of Retained Rectal Foreign Bodies. Am J Emerg Med 1988; 6: 385 -389.
ED Principles of Removal • • • Minimize cross-sectional are of removal device Simple is better: most successful FB removed with some type of snare, encasing forcep, or piercing tenaculum Remove under direct vision Overcome the suction effect Limit time: no more than 30 minutes Wigle RL. Emergency Department Management of Retained Rectal Foreign Bodies. Am J Emerg Med 1988; 6: 385 -389.
The Difficulty with Removing Rectal FB • • • FB usually has a smooth surface, difficult to grasp Often very friable (e. g. vegetable) or very hard (glass) Mucous/blood make traction and visualization difficult Anal sphincter may be is spasm or oedematous Rectal mucosa may be oedematous or bulging Curve of sacrum tends to hold the lower end of the FB away from the anus Blunt end of the FB usually presents caudally High-lying objects sometimes trapped either by rectosigmoid junction or the iliac spines Negative pressure may develop above the FB when traction is attempted, creating a suction effect on the FB Couch CJ et al. Rectal FB. Med J Aust 1986; 144: 512 -515
Palpable Rectal Foreign Bodies • Successful Post extraction management Trial of removal Unsuccessful Referral to General Surgery
Removal of the Palpable Foreign Body
Removal of the Palpable Foreign Body • • Local anesthetic written about but not used Sedate the patient well (propofol) • • Relax patient Relax anal sphincter Lithotomy position: helps to ease the passive tension of the abdominal wall muscles; heads up position assists with gravity Get a second pair of hands to apply pressure on the abdominal wall to prevent retrograde migration of FB. Not likely “uncharted waters”. Get a small pair of hands, ideally not yours. Be prepared to invest some time
Abdominal Pressure or Valsalva Maneuver
Removal Equipment & Techniques
Specific Tools of your “Arse-nal” • • Digital removal Parks retractors, vaginal speculum Tenaculum/Ringed Forceps Labour and Delivery Forceps Foley catheters, endotracheal tubes, Sengstaken-Blakemore tube Loop of wire, snares, or suture material Sheath (to cover an object with spikes)
Specific Tools of your “Arse-nal”: Heavy Equipment • • Proctoscope/Sigmoidoscope/Colonoscope • Important to check post removal for evidence of trauma/perforation: mucosal lacerations, bleeding, perforations, or missed foreign body Obstetric Vacuum Devices
Parks Rectal Retractor
Special considerations – Round, Firm • Rounds objects – orange, tennis ball, cue ball • • Vacuum extractor or Simpson’s obstetrical forceps Sponge or towel forceps Vibrators/dildos – towel clamps Organic material
Special considerations - Glass/Sharp Objects • • Sharp objects – surgery or GI Glass • consider x-ray prior to DRE • risk of breaking? • glass jar with opening towards anus - fill with plaster of Paris (Toomey syringe) & set with NG or retractor in place *** exothermic effect • Rubber-tipped forceps
Suction Effect • • • FB that obstruct entire lumen may create negative pressure zone proximal to object Overcome by insertion of venting device (foley catheter, endotracheal tube, Blakemore tube) Foley catheter with balloon inflated beyond or within FB can then be used to apply traction
Special considerations - Overcome the vacuum
Innovative Removal Techniques
Ingenious Removal Methods • • 27 y/o male, inserted light bulb into his rectum, screw end of the bulb facing Removal technique: light socket attached to end of a broom handle Socket screwed onto the bulb, then evacuated Benjamin HB et al. Removal of Exotic Foreign Objects from the Abdominal Orifices. 1969. 20; 6: 413 -414
Ingenious Removal Methods • • 54 y/o male, 2 days previously drinking whiskey, “did something” to his rectum Later admitted he accepted a wager of $100 and used shaving cream as a lubricant • • Difficulty defecating and urinating Rectal exam: hard, smooth globular mass • Removal technique: toy darts with suction cups used to draw electric bulb to sphincter; surface of exposed glass dried with ethyl ether swabs, then attempted to attach suction cup again with cyanoacrylate cement; eventually removed with 3 # 24 foley catheters • Diwan VS et al. Removal of 100 Watt Electric Bulb from Rectum. Ann Emerg Med 1982. 11; 11: 643 -644
Ingenious Removal Methods • • 28 y/o female, misadventure with boyfriend Vibrator lost in rectum, boyfriend tried to retrieve with salad tongs, which became lost as well • Removal technique: laparoscopy used to push the rectal foreign body from above while it was reoved transanally from below • Personal communication with Dr. E. Debru and Dr. I. Walker
Ingenious Removal Methods • • Petanque Boule: shiny metallic sphere 7. 5 cm in diameter and 750 grams Boule palpable at fingertip, resting at rectosigmoid junction Bronson EM 301 electromagnet attached to 15 cm probe, delivered to anus, then shorter 3 cm probe attached Coulson CJ et al. Extraction of rectal foreign body using an electromagnet. Int J Colorectal Dis (2005) 20: 194 -195
Petanque Balls
Ingenious Removal Methods • • 44 y/o male, introduced a large cellophanecovered green apple into the rectum 24 hours prior to admission Surface of the solid foreign body treated with an argon beam coagulator, melting down the apple continuously After 2. 5 hours, apple melted down to less than 50% its original size, remainder removed with foreign body forceps Glaser J et al. Unusual Rectal Foreign Body: Treatment Using Argon. Beam Coagulation. Endoscopy 1997; 29: 230 -231
Apple Crisp
Unusual Rectal Foreign Bodies from the Top Down
Unusual Rectal Foreign Bodies: “From the Top Down” • • • Ingested Foreign bodies accidentally or intentionally can result in rectal FB’s, obstruction and perforation Risk factors: • • • small children patients with altered LOC (alcohol or drug use), dementia, consumption of high risk foods (chicken or fish bones), illicit activities (drug smuggling), structural abnormalities of GI tract (marble, ulcerative colitis and rectal stricture) Bloom R et al. Foreign Bodies in the gastrointestinal tract. Am Surg
Unusual Rectal Foreign Bodies: “From the Top Down” • • • Fish and chicken bones Toothpicks Pessaries IUD VP shunt catheters Angiographic catheters (hepatic artery) Migrated esophageal Souttar’s stent Migrated colonic stents Sunflower seed rectal bezoar, fruit and vegetable bezoars Body packers, Body stuffers
Complications
Complications • • • Traumatic disruption of sphincteric complex Intramural rectal hematoma (may present with obstructive symptoms) Case report: mucosal burns from leaking vibrator batteries Bowel obstruction Urinary retention Perforation of bowel wall Pelvic abcesses, perivesicular abcess, pelvic cellulitis, Fournier’s gangrene, septic shock Case report: 2 y/o male, rectal thermometer broke, small perforation in posterior rectal wall, migrated into epidural space Case report: 5 y/o male, rectal thermometer broke, fragments retrieved, 6 months later presented with dysuria, hematuria, and passed a few drops of mercury in urine, transvesicular migration Extreme embarrassment
Complications • • Case report: 58 y/o male, confusion, inability to speak, PMhx: rectosigmoid plastic soda bottle extraction 2 years previously Febrile, tachycardic, hypotensive Apical pansystolic murmur, mixed receptive and expressive aphasia, right hemiparesis, perianal erthyma, diminished sphincter tone MRI: infarction of occipital and frontal lobes TEE: vegetations of mitral valve Blood cultures: MSSA Treatment: nafcillin and gentamycin • Hypothesis: frequent colonization of rectum by S. Aureus, trauma to mucosa with secondary bacteremia and endocarditis • Pandey BB et al. Embolic stroke complicating S. Aureus Endocarditis circumstantially linked to rectal trauma from foreign body: a first case report. BMC Infectious Diseases 2005, 5: 42
Rectosigmoid injuries • Rectal Organ Injury Scale of the American Association for the Surgery of Trauma • • • The American Association for the Surgery of Trauma has proposed a Rectal Organ Injury Scale: Grade I — Hematoma: Contusion or hematoma without devascularization Laceration: Partial-thickness • • Grade II — Laceration ≤ 50 percent circumference Grade III — Laceration >50 percent circumference Grade IV — Full-thickness laceration with extension into the perineum Grade V — Devascularized segment • Moore EE et al. Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma. 1990 Nov; 30(11): 1427 -9
Rectosigmoid injuries • Full thickness injuries rare, if occur 60% due to FB insertion, 30% fist fornication, 10% due to penile intercourse • Perforations above peritoneal reflection: pneumoperitoneum, signs of peritonitis • Perforations below: water soluble contrast enema or sigmoidoscopy, may have delayed presentation • Perforation not limited to sharp objects but rather to the force of introduction • No prediction models for duration of time rectal FB remain in situ to perforation; case reports of clinical presentation of perforation 72 hours post removal • Barone JE et al. Perforation and foreign bodies of the rectum, report of 28 cases. Ann Surg 1976; 184: 601 -604
Surgical Management: • • • Dictated by degree of injury and fecal contamination Small clean wound with clean edges: primary repair Gross fecal contamination: abdominal irrigation with repair or resection of injured colon and proximal end sigmoid colostomy, with mucous fistula or Hartmann’s procedure treatment of choice
Post Extraction Management • • Sigmoidoscopy Observation and repeat examinations • Discharge Instructions • • Avoid repeated trauma: “Never do that again” Fever Increasing abdominal pain Urinary retention
Dispostion: Outpatient versus Inpatient management • • • Controversy exists regarding outpatient versus inpatient observation management of patients with rectosigmoid lacerations Largest review of rectosigmoid lacerations caused exclusively by anorectal eroticism supports discharge of patients with minor lacerations after thorough ED work-up Hicks TC, Opelka FG. The hazards of anal sexual eroticism. Persp Colon Rectal Surg 1994; 7: 37 -57
Long-term complications • • Data extraction from prospective computerized data base April 1989 -April 1997, Singapore General Hospital 30 patients (25 men, 5 women) Standardized management protocol Clinical features, results analysed: • • • 12: transanal recovery with sedation General anesthesia in 13 Laparotomy in 3 Long-term follow-up by telephone interview at 63 months follow-up, in addition to hospital and public hospital medical records review No long-term complications of faecal incontinence or re-impaction of FB Boon-Swee Ooi et al. Management of Anorectal Foreign Bodies: A Cause of Obscure Anal Pain. Aust. N. Z. J. Surg. (1998)68, 852 -855
Legal Ramifications
Pediatrics • • • Child abuse or deviant sexual activity account for most rectal injuries in children; Exception: straddle injuries No FB in this series Only 2 Case reports in literature: 14 y/o male with empty soda can in rectum, 14 y/o male with vibrator in rectum Case report: chewing gum bezoars of GI tract; 4 ½ year old boy and girl, swallowed 5 -7 pieces of gum/day, presented with constipation and encopresis Black CT et al. Ano-rectal Trauma in children. Journal of Pediatric Surgery 1982; 17(5): 501 -4
Legal Ramifications: Drug Mules • Involvement of practitioner with patients who conceal illicit drugs within their rectums automatically entails legal responsibility • 2 circumstances: patient in custody of legal authorities, patient comes in on own • Unstable: treat • High risk of container rupture following instrumentation of any kind • Stable: If patient refuses consent, cannot remove anything. Considered as assault. • Stable: Can send to lab as FB removal for identification; medical indication in the event symptoms develop; on independent investigation, police can then can subpoena results from hospital laboratory • Warrant does not permit you to talk to legal authorities or conduct FB removal • Discussion with CMPA January 15 th 2009 Dr. Wayne Helmer
Drug Mule
Legal Ramifications: Assault • Treat as any other sexual assault • Activate CSART for collection and preservation of evidence • Ideally swabbing with gauze (ideally forensic swab, sterile swab without media)
Guess What I am?
Image 1: • Where is the ring?
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Epoxy Case Details • Case: 27 y/o male, presented with lower abdominal discomfort 5 hours post injection of a liquid adhesive (epoxyacrylate resin) into his rectum with a dual-chambered glue gun • Instantaneous exothermic reaction caused mixture to solidify and become fixed internally
Image 11: Epoxy Cast of Rectum
Conclusions • High index of suspicion in non-specific abdominal pain in the setting of inconsistent history and physical findings • Consider ED removal in selected cases of low-lying foreign bodies under direct visualization • Consider post-removal sigmoidoscopy/colonoscopy, duration of post-removal observation unclear • Risk of perforation higher correlation to force of introduction than to type of foreign body • Serious morbidity and mortality • Insert at your own risk
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