■ Clinical symptoms of perforation: Fever, leukocytosis, abdominal pain,
peritoneal signs, rectal bleeding
■ Radiographic signs of perforation: Free air under the diaphragm (intraperi-
toneal perforation) or free air tracking along the psoas muscle (retroperi-
toneal perforation)
TREATMENT
■ Simple foreign bodies may be removed in ED. Foreign bodies that are
large or with sharp edges may require surgical removal.
■ Technique of ED removal
■ Anesthetic: IV sedation should be considered. With patient in the lithotomy
position, inject an intradermal wheal at the 6- and 11-o’clock positions of
the anal canal. Insert one finger into the anal canal to guide the injection of
a further 5 mL of anesthetic into each quadrant of the internal sphincter.
■ Removal: Place a catheter beyond the object and inject air to overcome
the vacuum created by traction on the object and pull. Alternatively, a
Foley catheter may be used; after air is injected behind the object, then
inflate the balloon to aid in delivery of the foreign body.
COMPLICATIONS
■ Perforation may require emergency surgery.
■ If perforation is suspected, serial X-rays and proctoscopic exams are indi-
cated. If in doubt, the patient should be observed for 11 hours.
■ Administer antibiotics for perforation or excessive manipulation.
Hemorrhoids
Hemorrhoids are vascular complexes that line and protect the anal canal; they
become symptomatic with activities that increase venous pressure, causing
engorgement. Engorged, prolapsed, or thrombosed hemorrhoidal veins/arteri-
oles cause symptoms.
Internal:Located proximal to dentate line drain; insensate area
External:Located distal to dentate line; richly innervated
ABDOMINAL AND GASTROINTESTINALEMERGENCIESFIGURE 11.7. Goodsall’s rule.
(Reproduced, with permission, from Tintinalli JE, Kelen GD, Stapczynski JS. Emergency
Medicine: A Comprehensive Study Guide, 6th ed. New York: McGraw-Hill, 2004.)
Visceral perforation is the
most serious complication of
rectal foreign bodies.