Retained Colorectal Foreign Body After Suspected Chemical Incapacitation: A Surgical and Forensic Challenge

ABSTRACT

Retained rectal foreign bodies are an uncommon but clinically significant surgical emergency. We report the case of a 74‐year‐old male with multiple medical comorbidities who presented with progressive rectal pain and obstipation several days after an episode of suspected drug‐facilitated assault. Plain radiography identified a large metallic aerosol can, and attempts to retrieve it under general anesthesia using surgical clamps and a magnetic probe failed. Intraoperative fluoroscopy demonstrated that the can had migrated proximal to the rectosigmoid junction into the left colon, precluding transanal extraction. The patient underwent exploratory laparotomy with longitudinal colotomy, permitting safe removal of the foreign body without evidence of perforation or visceral injury. This case illustrates the critical role of intraoperative fluoroscopy when digital examination fails, the indications for operative intervention in proximally migrated foreign bodies, and the importance of considering drug‐facilitated assault as an etiology.

Key Clinical Message

Retained rectal foreign bodies may present after suspected drug‐facilitated assault and can migrate proximally beyond the reach of transanal retrieval. Early imaging and intraoperative fluoroscopy are essential for localization, ruling out perforation, and surgical planning, as delayed presentation may necessitate exploratory laparotomy and colotomy.

1. Introduction

Retained rectal foreign bodies are a well‐described but relatively uncommon surgical presentation. Patients frequently delay seeking medical attention because of embarrassment, resulting in prolonged impaction and increased risk of complications including perforation, ischemia, obstruction, bleeding, and sepsis. The majority of reported cases involve voluntary insertion for sexual gratification; however, accidental insertion, assault, and psychiatric illness have also been described [1]. The spectrum of retained objects is broad and includes bottles, cans, sex toys, household items, and sharp metallic objects.

Management depends largely on the location and morphology of the foreign body as well as the presence of complications. Distal rectal objects may often be removed manually or endoscopically, whereas proximally migrated or large foreign bodies frequently require operative intervention. Surgical approaches range from transanal extraction under anesthesia to laparoscopic or open colotomy. Delayed diagnosis and repeated unsuccessful extraction attempts may increase the risk of mucosal injury and perforation [2].

We report a case of a large metallic foreign body in an elderly male who presented after a suspected drug‐facilitated assault. The foreign body had migrated proximally into the left colon and ultimately required exploratory laparotomy with colotomy for extraction after failed transanal retrieval attempts.

2. Case History/ Examination

A 74‐year‐old male with a past medical history significant for Type 2 diabetes mellitus, chronic kidney disease, and hypertension presented to the emergency department in the evening with rectal pain, rectal fullness, and inability to defecate. The patient reported attending a social gathering, during which he denied alcohol consumption or illicit drug use. He recalled drinking juice at the gathering, after which he had a complete loss of memory. His next recollection was awakening on the street at approximately 9 PM later that evening.

Following the event, the patient developed progressive rectal discomfort, pelvic pressure, and constipation. He denied knowingly inserting any object into the rectum and was unable to explain the circumstances surrounding his symptoms. Due to persistent pain and inability to pass stool, he sought medical attention 3 days later.

On presentation, vital signs included blood pressure 152/86 mmHg, pulse 73 beats/min, respiratory rate 18 breaths/min, temperature 98.4°F (36.9°C), and oxygen saturation 92% on room air. Physical examination revealed an acutely ill‐appearing elderly male in discomfort. Abdominal examination demonstrated mild lower abdominal tenderness without overt peritoneal signs. Rectal examination was notable for severe tenderness and a sensation of rectal fullness, although no foreign body was palpable digitally.

3. Methods

Initial assessment raised concern for a retained rectal foreign body with associated proctalgia and possible bowel obstruction. An abdominal/pelvic Xray was obtained while confirming the presence of an elongated foreign body within the midline pelvic region. No pneumothorax was noted. The patient was admitted for further management. He was kept NPO and initiated on intravenous fluids, empiric piperacillin‐tazobactam, and analgesic therapy. General surgery was consulted, and due to concern that the object would not be amenable to bedside extraction, the patient was taken to the operating room the next day for examination under anesthesia and attempted retrieval.

4. Conclusions and Results

Manual rectal examination failed to palpate the foreign body. Given the positioning of the foreign body in the pelvic midline, manual extraction was attempted first. Longer surgical clamps were used in an attempt to contact and retrieve the object without success. A magnet was additionally employed due to concern about a metallic foreign body; however, extraction remained unsuccessful. Intraoperative fluoroscopy was subsequently performed and demonstrated a large metallic object located significantly more proximal than initially anticipated, appearing within the left colon.

Given the proximity of the object and the inability to safely retrieve it transanally, the procedure was converted to an exploratory laparotomy. A longitudinal colotomy was created, allowing the removal of the foreign body, identified as a large metallic mousse can. The foreign body is shown in Figures 1 and 2 below.

FIGURE 1.

Foreign body being extracted from the colon by longitudinal colotomy.

FIGURE 2.

Foreign body after removal.

5. Discussion

Retained colorectal foreign bodies range in severity from self‐limited distal impactions amenable to bedside extraction to complex proximal migrations requiring operative intervention. The present case is notable on several dimensions: the age and comorbidity burden of the patient, the proximal migration of an unusually large metallic object beyond the reach of manual and instrumentally assisted transanal retrieval, the indispensable diagnostic role of intraoperative fluoroscopy, and the clinical and medicolegal complexity introduced by a probable drug‐facilitated assault as the mechanism of insertion.

The initial clinical assessment of a retained rectal foreign body should incorporate plain abdominal radiography as a first‐line imaging modality for radiopaque objects [3]. Computed tomography (CT) of the abdomen and pelvis with contrast is indicated when perforation, migration above the peritoneal reflection, or hollow viscus injury is suspected, and provides superior delineation of object morphology, location, and adjacent tissue involvement. In the present case, plain radiography established the diagnosis, but the extent of proximal migration was not fully appreciated until intraoperative fluoroscopy was performed. This underscores the value of real‐time fluoroscopic guidance when initial examination under anesthesia fails to localize the foreign body.

Management algorithms for retained rectal foreign bodies are stratified principally by object location, morphology, and the presence of complications. Distally located objects, particularly those palpable on digital examination, are amenable to bedside or procedural suite extraction under conscious sedation using forceps, Foley catheters inflated proximal to the object, or rigid and flexible endoscopic instruments. Vacuum effects created by smooth cylindrical objects may be overcome by introducing a lubricated tube alongside the object to equalize intrarectal pressure, facilitating extraction. Importantly, perforation is ruled out prior to manual manipulation. When these measures fail, or the object is not palpable, examination under anesthesia with muscle relaxation allows more thorough digital and instrumented exploration. Operative intervention is warranted in cases of proximal migration, large object size, smooth‐surfaced objects precluding instrumental grasp, sharp objects at risk of causing transmural injury during transanal retrieval, and any case complicated by perforation, ischemia, or sepsis [4].

The surgical approach in this case: exploratory laparotomy with longitudinal colotomy is consistent with established management principles for proximally impacted colorectal foreign bodies. Laparoscopic approaches have been described in contemporary literature and may be preferable in hemodynamically stable patients without evidence of perforation, as they are associated with shorter convalescence and reduced perioperative morbidity. Conversion to open laparotomy, as occurred here, remains appropriate when laparoscopic manipulation is technically infeasible or unsafe [5]. Primary colotomy closure, as was performed, is generally acceptable in the absence of gross contamination, fecal spillage, or significant bowel wall ischemia. Diverting ostomy is reserved for cases in which bowel viability or tissue integrity is compromised.

The circumstances of this case warrant special attention to the possibility of drug‐facilitated assault. While it is certainly plausible that patients deny memory of events leading to rectal insertion of foreign bodies out of embarrassment, physicians have a responsibility to have a trusting and non‐judgmental approach. Drug‐facilitated sexual assault is not uncommon and appears to be on the rise. Commonly implicated drugs like gamma‐hydroxybutyrate (GHB) and flunitrazepam (Rohypnol) produce dose‐dependent anterograde amnesia, sedation, and loss of volitional control [6]. Urine GHB levels may remain detectable for up to 72 h and testing should be pursued whenever the clinical suspicion is sufficiently high. It is not clear whether a forensic examination was conducted in our patient.

Author Contributions

Rohan Karkra: writing – original draft, visualization, conceptualization. Kenneth R. Wilhalme Jr.: conceptualization, writing – original draft, visualization. Sameer Rao: writing – original draft. Ethan Shamsian: writing – original draft. Vraj Shah: writing – original draft. Edwin Teehan: supervision, writing – review and editing. Sima Vossough‐Teehan: supervision, writing – review and editing.

Funding

The authors have nothing to report.

Consent

Written informed consent from the patient was obtained according to journal guidelines.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.