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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Monday, December 31, 2018

The Anoscope for Foreign Bodies in the Rectum

Rectal exams are difficult for the patient and require true expertise. You cannot expect to complete a good rectal exam or remove a rectal foreign body without the correct information, good bedside relationship, and the right equipment.

Ensuring your patient has confidence in your ability is vital. Take the time to get to know what equipment is available in your ED. It's important to know what to do before a patient comes to your department with a rectal complaint.

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Most departments have a box dedicated to the anoscope. It typically will have two handles for light sources and two sizes of obturators with casing. The items that are not opened will remain sterile, but all other items must be sent to central processing for cleaning and sterilization after use. Photos by Martha Roberts.

The majority of patients who need rectal examinations typically require simple digital exam and proper questioning. A formal anoscopic exam may be necessary if a patient has inserted an object into his rectum that needs removal. It may also be useful to evaluate rectal pain, bleeding, and hemorrhoids. This may often require an x-ray of the abdomen or pelvis.

The anoscope is an excellent tool to complete the full exam. Pelvic speculums may be used if one is not available. A rectal block or expert consultation is warranted if the procedure requires more intricate steps.

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Obturators and scopes in two various sizes. Photos by Martha Roberts.

A patient with a rectal foreign body is often afraid to discuss what happened. Occasionally, patients may not know if objects are still present. This should not shock you or deter your questioning. Your task is to discuss this objectively with the patient in a nonjudgmental way. They are more likely to discuss the object inserted if they feel comfortable with you. It is important to know when, how, and where but never why.

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This patient at first said she fell on top of something before saying she purposely placed an object in her vagina. No foreign body was found on vaginal exam, but a plain A/P radiograph of the pelvis showed a foreign body in the rectum. After several rounds of questioning and some lorazepam to calm her, she explained what happened. We let surgery handle the case under sedation because the item, a vibrator, had several pieces and was too far inserted for simple bedside retrieval.

Occasionally, patients may have objects that migrated, like a patient with a recent gastrointestinal procedure that involved esophageal clipping. The clip had migrated into the rectum and could not be passed.

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These images show various endoscopic clips and a feeding tube in the abdomen. The square clip at the anal canal was identified as an Ovesco or bear claw clip, which was used in an upper GI procedure the patient had months earlier. The clip is hard, sharp, and dangerous. This patient required expert consultation once our anoscopic exam failed to remove the piece adhered to the anal canal.

These objects are sharp and can cause harm if you do a digital exam. Take a thorough history before doing a digital rectal exam. You can remove the object if you feel confident that you can without an anoscopic exam. If not, complete a full anorectal exam using these pearls:

The Approach

  • Identify the foreign body in the rectum.
  • Remove it with an anoscope.
  • Use a rectal block if needed for pain control.

Key Concepts

  • Inspect the anus and perform a block if needed.
  • Insert the scope into the rectum properly using excessive lubricant.
  • Remove the obturator and visualize the rectum.
  • Inspect the anorectal mucosa while withdrawing the scope.
  • Rotate 90 degrees and visualize a full 360 degrees.

The Pause

  • Involve specialists early if colorectal or surgical consultation is needed. It is not appropriate to do multiple rectal exams and anoscopic exams for patients with difficult foreign bodies. This can cause trauma and physical and emotional harm to patients.
  • Immediately discuss the procedure with the patient. Most if not all patients would like to know what objects or equipment might be involved in the process. Show them the equipment and explain the procedure before starting. Maintain a nonjudgmental attitude that is reassuring for the patient. Consider prior medical history such as anxiety, depression, and PTSD.
  • Offer anxiolytics or pain relief during this procedure. This may mean the use of oral or IV benzodiazepines or narcotics. Propofol may be indicated for procedural sedation if the object is far up in the rectum.

The Procedure

  • Allow patients to be comfortable. The lithotomy position is preferred. Another way to complete this procedure is to have the patient lay on his side in a left lateral position or fetal position. A partner may help hold the gluteal cleft open for larger patients. A patient may prefer to be on his back if a gynecological bed is available.
  • Always tell a patient what you will do before touching him.
  • Insert all equipment slowly and give relaxing messages to your patient.
  • Excessive lubricant is suggested.
  • Be patient. It may take a few deep breaths or encouragement to relax the muscles of the anus.
  • See our video below to see how to insert the anoscope.
  • Once you have targeted your object, you will need to remove it with the right equipment. Make sure you have forceps, tweezers, and hemostats ready. Do not make a patient wait while an assistant gathers this equipment.
  • A rectal block prior to internal exam may be appropriate, especially if painful hemorrhoids are present.
  • Draw up two 10 mL syringes of 1% lidocaine. Anorectal blocks involve anesthetizing the subcutaneous tissue of the anus using a 27 g needle (about 2 cm) with 1% lidocaine or bupivacaine.
  • First complete a subcutaneous circle of local anesthesia around the anus, about 2 cm in diameter. Inject at the 12, 3, 6, and 9 o'clock positions. Inject 3-4 ml in each area while holding your needle at a 45-degree angle laterally. See our video for technique.
  • You can then dilate the rectum with a speculum or obturator for your exam and complete further pain relief blocks. Be sure to visualize a 360-degree spectrum of the rectum.

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Watch a video showing how to use an anoscope and how to do a rectal block.

Cautions

  • Sharp foreign bodies need expert consultation. These can be dangerous for the patient and can tear the skin and rectum. It can also be dangerous for the provider and cause injury.
  • Patients must be comfortable and relaxed. Attempt to do this without medications, but occasionally oral or IV anxiolytics such as lorazepam or diazepam are appropriate. Pain control is not typically necessary, but it depends on your assessment.
  • Moderate sedation with propofol may also be an option. Discuss options with the patient and your surgical team.
  • Perforation of the rectal mucosa can lead to abscess formation.
  • Food, wood, and glass can cause perianal infections and lead to sepsis.
  • Because of potential complications, rectal foreign bodies should be regarded as serious emergencies and treated expeditiously.