Rosen & Barkin's 5-Minute Emergency Medicine Consult (602 page)

• Injury to rectal mucosa
  
• Simple contusion to full-thickness laceration with extension into peritoneum or perineum
  
• 2/3 of rectum is extraperitoneal.
  

• Penetrating trauma:
  
  • Gunshot wounds: 80% penetrating rectal trauma
    
  • Knife wounds
    
  • Impalement injuries
    
• Blunt trauma:
  
  • Motor vehicle accidents
    
  • Waterskiing and watercraft accidents:
    
    • Hydrostatic pressure injury
      
  • Pelvic fractures:
    
    • Bony fragments penetrate rectum
      
• Foreign body:
  
  • Autoeroticism
    
  • Anal intercourse
    
  • Assault
    
  • Ingestion of sharp objects
    
• Iatrogenic trauma: Most common cause of rectal injury:
  
  • Barium enema:
    
    • Perforation occurs in 0.04% patients
      
    • 50% mortality
      
  • Colonoscopy:
    
    • 0.2% perforation rate
      
    • Increased risk with polypectomy
      
  • Hemorrhoidectomy
    
  • Urologic and Ob-Gyn procedures:
    
    • Episiotomy
      

• Rectal injury may result from thermometer insertion.
  
• Any rectal trauma in young children should raise the suspicion of nonaccidental trauma.
  

DIAGNOSIS

• Perineal, anal, or lower abdominal pain
  
• Signs of perforation or peritonitis:
  
  • Guarding
    
  • Rebound tenderness
    
  • Fever
    
• Rectal bleeding
  
• Obstipation
  
• Presence of pelvic fracture
  
• History of anal manipulation, foreign-body insertion, sexual abuse
  

• Time and mechanism of injury
  
• Suspect rectal injury in all patients with gunshot wound, stab wound, or impalement injury to trunk, buttocks, perineum, or upper thigh.
  
• Consider in any patient with history of anal manipulation complaining of lower abdominal or pelvic pain.
  

• Inspect and palpate thoroughly buttocks, anus, and perineum.
  
• Identify entrance and exit wounds if penetrating trauma.
  
• Perform digital rectal exam:
  
  • Assess for gross blood or guaiac-positive stool
    
  • Note position of prostate
    
• Assess perineal integrity:
  
  • Speculum and bimanual exam in all female patients
    
  • Thorough genitourinary exam in all male patients, including prostate exam
    

• Labs: CBC, urinalysis
  
• Acute abdominal series
  
• CT abdomen and pelvis if blunt trauma
  
• Sigmoidoscopy: Following extraction of foreign body
  
• Evidentiary exam: Required in cases of sexual assault
  

• CBC:
  
  • Blood loss
    
  • Leukocytosis/bandemia suggesting peritonitis
    
• Type and screen:
  
  • If evidence of hemorrhage
    
• Urinalysis:
  
  • Evaluate for fecal matter
    

• Supine/upright abdominal films, pelvic radiographs:
  
  • Evaluate for pneumoperitoneum or extraperitoneal and extrarectal densities suggesting perforation.
    
  • Identify location, size, and shape of foreign body.
    
  • Identify pelvic fracture or diastasis of symphysis pubis, which may accompany rectal injury.
    
• CT abdomen and pelvis
  
  • IV, PO, or PR contrast (gastrografin) per the clinical situation
    

• Retrograde urethrogram if high-riding prostate noted on rectal exam
  
• Contrast enema helpful only in situations where perforation is unclear:
  
  • Water-soluble contrast (e.g., gastrografin)
    

• Colon injuries
  
• Genitourinary injuries
  

TREATMENT

• Airway, breathing, and circulation
  
• Spinal precautions if blunt trauma
  
• Fluid resuscitation if blood loss, hypotension
  
• Do not attempt removal of rectal foreign body
  
• Control bleeding
  

Penetrating or blunt abdominal trauma, follow trauma protocols:

• Primary survey
  
• Resuscitation
  
• Secondary survey
  
• Treatment
  

• Tetanus prophylaxis if needed
  
• Broad-spectrum antibiotics if significant mucosal disruption or signs of peritonitis are present
  
• Foley catheter (after excluding urethral injury)
  
• Rectal foreign body removal in ED:
  
  • Determine location and type of foreign object
    
  • Sedation:
    
    • Avoid sedation if possible; ideally, patient can aid extraction by bearing down during procedure
      
  • With patient in lithotomy position:
    
    • Local anesthesia to maximize anal sphincter dilation
      
    • Gentle digital sphincter dilation
      
    • Obstetric, ring, or biopsy forceps, tenaculum, or suctioning device to aid extraction
      
    • Suprapubic pressure
      
    • Patient Valsalva
      
  • Foley catheter:
    
    • Pass above foreign body, inflate balloon, and apply gentle traction to release suction and permit extraction
      
    • Using 3 catheters, pass each alongside of foreign body, inflate, and gently pull (helpful for smooth objects or if unable to pass Foley above object)
      
  • Sigmoidoscopy to evaluate mucosal injury following extraction
    
• Surgical consultation:
  
  • Peritonitis
    
  • All traumatic rectal mucosal lacerations
    
  • Objects >10 cm from anal verge
    
  • Sharp objects whose removal may provoke mucosal injury
    
  • Inability to extract foreign body in ED
    

• Antibiotics with coverage against gram-negative and anaerobic organisms:
  
  • Ampicillin/sulbactam:
    
    • Adults: 3 g q6h IV (peds: 50 mg/kg IV)
      
  • Cefotetan:
    
    • Adults: 2 g q12h IV (peds: 40 mg/kg IV)
      
  • Cefoxitin:
    
    • Adults: 2 g q6h IV (peds: 80 mg/kg q6h IV)
      
  • Piperacillin/tazobactam:
    
    • Adults: 3.375 g IV (peds: 75 mg/kg IV)
      
  • Ticarcillin/clavulanate:
    
    • Adults: 3.1 g IV (peds: 75 mg/kg IV)
      
• Additional anaerobic coverage:
  
  • Clindamycin:
    
    • Adults: 600–900 mg IV (peds: 10 mg/kg IV)
      
  • Metronidazole:
    
    • Adults: 1 g IV (peds: 15 mg/kg IV)
      
• Combination therapy:
  
  • Adults: Ampicillin 500 mg IV q6h, gentamicin 1–1.7 mg/kg IV, and metronidazole 1 g IV
    
  • Peds: Ampicillin 50 mg/kg IV q6h, gentamicin 1–1.7 mg/kg IV, and metronidazole 15 mg/kg IV
    
• Sedation and analgesia:
  
  • Fentanyl: 2–3 μg/kg IV (peds and adults)
    
  • Midazolam: 0.01–0.2 mg/kg IV (peds and adults)
    
  • Lidocaine: Topical or injectable
    

• Perforation
  
• Torn sphincter
  
• Foreign body:
  
  • General anesthesia required to remove high-riding or sharp object
    
  • Laparotomy is last resort
    

FOLLOW-UP

• Perforation
  
• Significant bleeding
  
• Unstable vital signs
  
• Abdominal pain
  
• Torn anal sphincter
  
• Foreign body that requires extraction in operating room
  

• Stable vital signs
  
• No abdominal pain
  
• Normal sigmoidoscopy/anoscopy exam
  

• Repeat abdominal exam 12–24 hr
  
• Return to ED:
  
  • Abdominal pain
    
  • Vomiting
    
  • Fever
    

• Consider rectal injury in all patients presenting with abdominal pain following lower GI or genitourinary procedure.
  
• 60% of foreign bodies can be removed in ED.
  
• Failure to recognize perforation following extraction of foreign body
  
• Creativity and imagination can aid successful extraction of foreign body in ED.
  

• Bak Y, Merriam M, Neff M, et al. Novel approach to rectal foreign body extraction.
  JSLS
  . 2013;17(2):342–345.
  
• Cleary RK, Pomerantz RA, Lampman RM. Colon and rectal injuries.
  Dis Colon Rectum
  . 2006;49(8):1203–1222.
  
• Manimaran N, Shorafa M, Eccersley J. Blow as well as pull: An innovative technique for dealing with a rectal foreign body.
  Colorectal Dis
  . 2009;11:325–326.
  
• Tonolini M. Images in medicine: Diagnosis and pre-surgical triage of transanal rectal injury using multidetector CT with water-soluble contrast enema.
  J Emerg Trauma Shock
  . 2013;6(3):213–215.
  

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