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 29th, 2009
Accreditations/special thanks to:
• Dr. Eric Grafstein,
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MD,FRCP
Dr. Rick Walker, MD FRCP
Ms. Monica Fredborg, RTR
• The following hairstyle
is associated with:
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A) rectal foreign bodies
B) a
C) a + b
D) all of the above
Objectives
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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:
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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.
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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.
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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 | OvidSP
Results of search
• 240 articles found
• 175 identified as possibly relevant
• Abstracts reviewed (large number of case studies,
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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
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Mostly case series, with ranges of 8 to 101 cases on average over
5 year periods,
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Calgary data, St. Paul’s data
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Incidence is increasing
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
• 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
Incidence and prevalence
•
UpToDate 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 3rd sacral
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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
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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,
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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,
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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,
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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”
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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
Bottle or jar
Bottle with
attached rope
Glass or cup
Wooden
Axe handle
Stick or broom
handle
Miscellaneous
Light bulb
Tube
Food
Apple
Banana
Carrot
Parsnip
Plantain (with
condom)
Potatoe
Balloon
Flashlight
Balloon attached to
Iron rod
Pen
Kitchen Devices
Dull knife
Screwdriver
Ice pick
Toothbrush
Knife
sharpener
Wire spring
Mortar & pestle
Inflated device
Candle
Rubber tube
cyl
Condom
Bicycle inner tube
Balls
Baseball
Tennis ball
Bocce ball
Misc Containers
Candlebox
Cucumber
Onion
Misc tools
Spatula
Snuffbox
(plastic)
• Busch DB et al. Rectal Foreign Bodies:
Case
Reports and a Comprehensive Review
of the can
World’s
Baby powder
SpoonLiterature. 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
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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
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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
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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
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What is the longest documented rectal FB
retrieved?:
• 14 inch piece of sandfilled bicycle inner tubing (close
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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
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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
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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
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Buzzard AJ et al. A Long-Standing, Much Travelled Rectal Foreign Body. Med.J. Aust.,
1979, 1:600
Approach
Management of Rectal Foreign Bodies
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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
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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
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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
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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
McDonald 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
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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
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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
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Focus on abdomen (to exclude perforation),inspection of anus, and careful
digital exam
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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
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The “vibrating umbilicus” sign (Mike Betzner)
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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
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Hammond EJ et al., An Unusual ECG. Anaesthesia, 2001, 56(4):402.
Anal Fibrillation
Role of Imaging
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Define the foreign body
Free air?
Is there only one?
Timing?
To provide content for
emergency medicine grand
rounds
Radiographic Detection of Foreign Bodies
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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)
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Radiopacity proportional to density or weight per unit volume of the material
examined
Denser material absorbs more photons
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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
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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
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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
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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
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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
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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
• Trial of removal
Successful
Unsuccessful
Post extraction
management
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)
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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”
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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
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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
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Rounds objects –
orange, tennis ball,
cue ball
• Vacuum extractor or Simpson’s
obstetrical forceps
• Sponge or towel forceps
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Vibrators/dildos –
towel clamps
Organic material
Special considerations - Glass/Sharp Objects
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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
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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
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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
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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
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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
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Personal communication with Dr. E. Debru and Dr. I. Walker
Ingenious Removal Methods
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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 cellophane•
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covered 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 ArgonBeam 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
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intentionally can result in rectal FB’s,
obstruction and perforation
Risk factors:
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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”
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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
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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
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Extreme embarrassment
Complications
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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
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Hypothesis: frequent colonization of rectum by S. Aureus, trauma to mucosa
with secondary bacteremia and endocarditis
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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
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Rectal Organ Injury Scale of the American Association for the Surgery of
Trauma
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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
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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
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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
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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
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Avoid repeated trauma: “Never do that again”
Fever
Increasing abdominal pain
Urinary retention
Dispostion: Outpatient versus Inpatient
management
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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
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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:
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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
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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 15th 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