eP104 - Take the Lid Off: Retained Rectal Foreign Body Removal Tips and Tricks

Purpose/Background: An 80-year-old male presented to the emergency department with a retained rectal foreign body (RFB). He stated he had been massaging his anus with a glass jar five days prior and it became lodged. He attempted manual retrieval repeatedly, but after three days of unsuccessful attempts, he visited the emergency department with worsening abdominal pain.

His vitals and lab work all were within normal limits. On physical exam a 10cm hard, cylindrical object was palpated in his left lower quadrant and with mild tenderness to palpation. Digital rectal exam (DRE) revealed blood-tinged mucus and a portion of a glass jar with metal lid attached about 3cm from the anal verge. An abdominal x-ray confirmed a lodged RFB. An upright chest x-ray revealed no signs of free air. Due to the size of the object and need for paralysis, the patient was taken to the operating room for extraction under anesthesia.Methods/Interventions: In the operating room, the patient was intubated, placed in the lithotomy position, and fully paralyzed. Given the jar’s width coupled with the patient’s narrow pelvis, the RFB was tightly confined by the bilateral ischial spines and coccyx. With an assistant’s application of external abdominal wall pressure, the surgeon attempted manual retrieval of the jar via the anal canal. Retrieval proved to be cumbersome given the jar’s slippery glass composition.

After multiple attempts, the decision was made to untwist and carefully remove the lid of the jar. Leveraging a sponge to grasp the now available top ridges of the glass jar, adequate leverage could be obtained to grip the jar and with continued external abdominal wall pressure, the jar was finally extracted (Figure 2). A rigid sigmoidoscopy was then performed. This demonstrated mildly inflamed mucosa without tears in the rectum or anus. On DRE, the sphincter muscles appeared intact.Results/Outcomes: The patient remained nil per mouth overnight and received 24 hours of antibiotics for proctitis. He transitioned successfully to a regular diet with non-bloody bowel movements post-operatively. He was safely discharged home.Conclusion/

Discussion: Documentation of RFBs dates to the 16th century, with glass bottles being the most common foreign object.1 There is no defined protocol on technical maneuvers to remove RFBs, though varied methods with the use of foley insertion, SILS ports, TAMIS, or laparotomies have been documented.2 In this elderly patient, we aimed to avoid performing a laparotomy to extract the RFB. By unscrewing the lid to the jar and leveraging the use of a sponge, we were able to grip the object more readily for successful extraction. We recommend this maneuver in patients with retained RFB, particularly for those RFB which are composed of smooth and difficult to grip (ie glass) composite. By removing the lid and using a sponge, a strong grip can be obtained on the lip of the jar that contains ridges which can be used for traction. This method allows for easier extraction and prevents escalation to more invasive retrieval methods.Take the Lid Off:Abdominal xray showing large retained RFB and the removed RFB with sponge and lid off.