A case
of Colorectal foreign body in a previously treated case of recto sigmoid
perforation is presented. A brief review of relevant literature is
presented.
Introduction
Variety of foreign bodies have been found into the rectum like turnip,
stick, tumbler, paper pot, screw driver, live shell, glass bottle,
vibrator, door handle, electric bulb, candles, fruits2-7 some are
introduced for diagnostic or therapeutic purpose like thermometer,
enema tubes, disposable enema tips, irrigation catheters.2 These foreign
bodies may cause iatrogenic perforations of sigmoid colon and rectum.8
Many cases of spontaneous or idiopathic perforations of sigmoid colon
are described in literature.8-13 Although literature states that most
of these idiopathic perforations are ischaemic or stercoral perforations
in chronically constipated subjects,8,9 one should keep in mind that
these perforations can be iatrogonic because of self introduction
of foreign body as it may be in present case.
Case Report
A 60 year old widowed Mohammedan male tailor was admitted in casualty
of government medical college hospital, Yavatmal as a case of perforation
peritonitis. After initial resuscitation exploratory laparotomy was
performed. Peritoneal cavity was found full of faecal matter and pus
which was drained by suction evacuation and gentle mopping with sterile
gauze packs. On examination stomach, duodenum, small gut and other
viscera were normal. Appendix, caecum and large bowel were also healthy.
However, there was large linear perforation on rectosigmoid colon.
It was sutured in two layers and a proximal iliac colostomy was established.
Post operative period of the patient was stormy but patient survived.
We at that time thought that it was one of the rare cases of spontaneous
perforation of healthy large bowel which usually involved rectum above
peritoneal reflection and sigmoid colon. After recovery patient discharged.
Later on his closure of colostomy was done after six weeks. “But,
Habit’s Die Hard?”
A year later same gentleman presented to us with complaints of pain
and uneasiness in the lower abdomen and difficulty in walking. At
this time he gave history that he has inserted a glass bottle into
the anorectum. Examination revealed that all vital parameters were
normal and there was no evidence of perforation or peritonitis nor
of bleeding. Per rectal examination confirmed the foreign body but
it could not be removed. X-ray AP and lateral views confirmed glass
bottle in pelvis (Fig. 1).
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| Fig.
1 : X-ray of pelvis showing glass bottle. |
Fig.
2 : Photograph of glass bottle extracted by laparotomy. |
Fig.
3 : Clinical photograph of patient. 1. shows previous
scar of closure of iliac colostomy. 2. shows transverse colostomy
opening. |
This
time it struck our mind that previous episode of sigmoid perforation
may be because of self introduction of some sharp foreign body. But
on asking history he denied self introduction of any foreign body.
He said that he had piles and for that he used to apply ointment with
the help of bottle but on rectal examination there were no piles.
He agreed that he used to introduce fingers for applying ointment.
An attempt was made to extract the bottle from anal opening but failed
as the broad base of the bottle was towards the anal verge and mouth
of the bottle was cephalad. Further gentle manipulatory attempts under
general anaesthetic were done but vigorous bimanual manipulatory attempts
were avoided because of previous surgery. Main reason for failure
of these attempts was probably the smooth broad base of the bottle
which was impacted and could not be firmly grasped by fingers.
Hence decision to go ahead with laparotomy is made. Abdomen was opened
by excising previous laparotomy scar operated for sigmoid perforation.
Foreign body palpated in sigmoid colon. It was very difficult to mobilize
it because of previous adhesions and foreign body impaction. Sigmoid
colon opened. Foreign body removed with difficulty (Fig. 2). Colon
sutured in 2 layers. This time proximal transverse colostomy established.
Post operative course was eventless (Fig. 3). Closure of colostomy
was done after 3 weeks. Patient is well and attending regular follow-up.
Discussion
Variety of foreign bodies which have found their way into the rectum
is hardly less remarkable than the ingenuity displayed in their removal.
The turnip has been delivered per anum by the use of obstetric forcep.1
A stick firmly impacted has been withdrawn by inserting a gimlet into
its lower end.1 A tumbler, mouth looking downwards has been extracted
by filling the interior with plaster of paris bandage, leaving the
end of the bandage protruding and allowing the plaster to set.1 The
Glass bottle can also be removed by the same method if mouth of the
glass bottle is directed caudally.2
Review of literature revealed following circumstances for which foreign
bodies are introduced into the rectum and colon.4-7
1. Dignostic or Therapeutic : e.g. Thermometer, enema tubes, disposable
enema tips, irrigation catheter etc.
2. Self administered : Treatment to alleviate symptoms of anorectal
diseases e.g. pruritus ani and to reduce proposed haemorrhoids.
3. Criminal assault : e.g. glass bottle
4. Auto-eroticism : e.g. vibrator
5. Accidental introduction.
These foreign bodies in the rectum are classified as
1. Low lying foreign bodies : Foreign bodies palpable in rectal ampulla
2. High lying foreign bodies : In or proximal to rectosigmoid junction
The peculiar problem of glass bottles in rectum is if the mouth of
the glass bottle is directed cephalad this will create a negative
pressure within the glass hollow drawing the mucosa in the mouth of
the container. Attempt at removal will be futile and injury to rectal
mucosa may result.2 An easy method is to use two or more
Foley’s catheters around the object and to inject air around
the opening of the container, after inflating the balloon of the catheter.
Applying gentle traction to the catheters will help in removing the
glass object. This way glass object can be removed intact and chances
of injury to anorectum because of breaking of the object will be minimized.2
High lying foreign bodies can be manipulated under general anaesthesia
and brought in the rectal ampulla and can be removed.2
Flexible fiber-optic colonoscope with a biopsy forces can be used
to remove the foreign bodies upto the caecum.2
If unsurmountable difficulty is experienced in grasping any foreign
body in the rectum a left lower laparotomy is necessary which allows
that object to be pushed from above into the assistant’s fingers
in the rectum.1 If there is a considerable laceration of
the mucosa a temporary colostomy is advisable1 as in the present case.
These foreign bodies can cause iatrogenic perforation of sigmoid colon
and rectum. While reviewing case reports in the literature it is noticed
that the idiopathic perforation of sigmoid colon is common in older
age group above 60.8 On gross examination intraoperatively
these perforations exactly look like spontaneous perforations of the
sigmoid colon which is clear cut, slit like or rarely ragged edged10,14
and commonly located on antimesenteric border of the bowel wall.8
Hence message is - In a patient of perforation of sigmoid colon and
rectum history of introduction of foreign body should be asked and
if present habitual patient be advised psychiatric counselling. Herewith
a case of colorectal foreign body in a previously treated case of
rectosigmoid perforation is presented.
References
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Ind Jour Surg 1995; 57 : 233-35.
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Ind Jour Surgy 1994; 56 (1) : 36-37.
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1 : 1422-25.
11. Huttunen R, et al. Stercoraceous and Idiopathic perforations of
the colon. Surg Gynaec Obstet 1975; 140 : 756-60.
12. Kirhanm CS. Spontaneous perforations of the normal pelvic colon.
Br J Surg 1966; 48 : 126-29.
13. Roy TT, et al. Spontaneous perforation of normal sigmoid colon.
Ind J Surg 1991; 53 : 428-30.
14. Goligher J. Injuries of rectum and colon in surgery of the Anus,
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Associate Professor, Department
of Surgery, Shri VN Government Medical College, Yavatmal, (MS), India.
