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15.5 Anal Adenocarcinoma
Adenocarcinoma is the second most common histological type of anal cancer, representing in most series fewer than 10% of anal cancers.
29
In others studies, a higher percentage
was reported (19% of anal cancers).
2
The incidence of anal ADC decreased or is stable in
most countries.
1
Several types of ADC were described and are classified according to the World Health
Organization
30
as colorectal type, of anal glands, and associated with anorectal fistula.
Most of these cancers are rectal adenocarcinomas extending to the anal canal or arising
in the colorectal type mucosa above the dentate line. There is no difference in patient
management between the two, but colorectal type ADC occurring within the anal canal
carries a higher risk of nodal disease along the inguinal and femoral nodal chains.
31
Anal
gland tumors usually originate from the anal ducts and have continuity with the anal
gland epithelium.
31
Adenocarcinoma within an anorectal fistula can be associated with
preexisting anal fistulas and can appear in Crohn’s disease patients.
32
Most patients have nonspecific symptoms and are diagnosed after assessment for a
supposedly benign anal condition.
31
The prognosis of anal ADC is poor and aggressive therapy should be considered.
10
When compared with anal SCC or rectal ADC the prognosis is worse,10although there
is a strong trend for improved survival among patients who receive radical surgery.
10
A multimodality approach, combining radical surgical resection with neoadjuvant/
adjuvant chemoradiotherapy, may be the best management strategy.
33
Anal ADC therapy
is normally approached according to the rectal cancer treatment guidelines.
26
15.6 Extramammary Paget Disease
EMPD is an intraepithelial adenocarcinoma that can affect several areas, namely the vulva
(most common), scrotum, penis, axilla, perianus, and the anal canal.
34, 35
Two types of
disease are described, a primary disease that is not associated with other malignancies
and a secondary type often associated with an underlying visceral malignancy.
36
The
initial site of disease seems to predict the site of the secondary malignancies.
36
Anorectal
Paget’s disease is frequently associated with an underlying colorectal and anal malignancy. This can occur simultaneously, and at the time of diagnosis it is important to
exclude other malignancies.
34,35
Long-term follow-up is also needed because of the pos-
sibility metachronous lesions.
36
In a study using data from the Surveillance, Epidemiology,
and End Results (SEER) Program, including 1439 patients who were diagnosed with invasive EMPD, no increased risk was found for melanoma of the skin, cancer of the stomach,
pancreas, lung, bronchus, bladder, kidney and renal pelvis, breast, ovary, cervix, lymphoma, and leukemia.
36
Other (small) studies have described associations with some
of these malignancies.
34
Chapter 15 • Anal Tumors 193
Perianal eczema/rash and pruritus
34, 35
are the most frequent symptoms. Many
lesions can mimic a benign dermatologic condition, with few symptoms, whi ch can
delay diagnosis.
35
A nonresponse to topical therapy should also raise suspicion
of EMPD.
Surgical excision is the standa rd treatment
35
and due to the size of some of these
lesions, there is a high associated morbid ity.
37
Metastasis can be present, although it
is are rare at disease diagnosis (3%).
36
In cases of noninv asive EMPD, the prognosis
is good and wide local excision is the recommended therapy.
35
Locally invasive perianal Paget disease usually requires a more radical surgical approach. Local recurrence is
often seen and re-excisions may be needed.
34
Radiotherapy and/or chemotherapy, topical pharmacotherapie s ( imiquimod or 5-FU), cryotherapy photodynamic therapy, and
laser have als o been described as other possible treatments, although with few published data.
37
15.7 Anal Melanoma
Anal melanoma is an uncommon malignancy, representing 4% of anal cancers.
9
Females
and older patients are the most commonly affected groups.
31
No other risk factors were
identified.
38
Rectal bleeding and sensation of an anal mass are frequent symptoms.39Lesions are
commonly large
38
and often pigmented, although 30% are amelanotic31(Fig. 15.3). When
comparing with other areas, anal melanoma is diagnosed later and usually remains undetected until it causes symptoms.
39
For the diagnosis an immunohistochemical confirma-
tion is important, with tumor cells expressing S-100 and HMB-45.
31
FIG. 15.3 Woman presenting with a very large anal mass (>5 cm). Histology confirmed an anal melanoma.
194 ANORECTAL DISORDERS
This is an aggressive malignancy with a poor prognosis,
9, 38
5-year survival is around
20%.
40
Surgery is the first-line therapy, with wide local excision or abdominoperineal resec-
tion being the major approaches.
38
The extent of surgical resection does not seem to significantly impact outcome/survival, as patients often die of distant metastases.
A retrospective study compared anal versus anorectal versus rectal melanomas as a prognostic factor (dentate line as an anatomic reference). Lesions at or proximal to the dentate
line corresponded to a more advanced disease. Those lesions distal to the dentate line more
commonly recurred within lymph nodes.
40
In this study the majority of patients with anal
melanoma underwent transanal excision, and patients with anorectal or rectal melanoma
underwent abdominoperineal resection. Radiotherapy and systemic adjuvant therapy
were also described as possible therapies, but without a clear benefit in survival.
31, 40
15.8 Anal Neuroendocrine Tumors
Anal neuroendocrine tumors are very rare, with few case reports in the anus and perianus.
They account for 1% of the anal canal malignancies.
41,42
In the perianal area they can
mimic hemorrhoids.
41
The outcome is poor with the majority of tumors being found with distant metasta-
ses.
42
Due to the rarity in this location, the ideal treatment is not clear. Surgery is normally
used,
42
with the extension dictated by the size.31For a more advanced disease, more
aggressive approaches should be considered.
31,41
15.9 Anal Lymphoma
Anal and rectal lymphomas are often described together; they are a rare malignancy and
most are non-Hodgkin lymphomas.
31
Some case reports have described anal lymphomas
presenting as anal abscesses.
43
Lymphoid tissue in the anal canal, that is aggregated
around the anal glands in the intersphincteric plane, can block these glands, therefore
contributing to abscess formation.
43
Some of the case reports of anal lymphoma were
described in HIV-positive patients.
44
15.10 Anal Mesenchymal Tumors
The most common types of anal mesenchymal tumors are smooth muscle tumors and
gastrointestinal stromal tumors (GISTs), although others can occur, like schwannomas
and sarcomas. Leiomyomas are benign smooth muscle tumors. Several case reports in
the anus/perianus were described and a close proximity with the anal sphincter can
occur.
45
Differential diagnosis, especially with GISTs, is important. Leiomyoma are positive for smooth muscle markers (smooth muscle actin and desmin), whereas GISTs are
mostly positive for CD117 and/or CD 34.
46
Surgery can be used as a therapeutic approach
and complete excision is necessary to avoid recurrence.
Chapter 15 • Anal Tumors 195
GISTs are c-kit protein-positive mesenchymal tumors. Anal and rectal GISTs are fre-
quently described together and are rare.
47
In the anal canal they usually comprise a lesion
in the intersphincteric space. Tumor size (>5cm) and mitotic index (>5 mitotic figures/50
high-power field) are recognized prognosis factors and are relevant for deciding the extent
of resection. Due to the rarity of anal involvement there is no established treatment,
although local excision can be used. Inhibitors of the tyrosine-kinase receptor are indicated for local and distant recurrence after surgical resection.
47
Schwannomas are slow-growing mesenchymal neoplasms that arise from Schwann
cells. Few cases have been reported in the anal or perianal area.
48,49
They are usually
asymptomatic and present as a large mass,
48
with a very low rate of malignant transfor-
mation.
49
Occasionally symptoms can occur due to compression/mass effect.49Immunohistochemistry is important for a differential diagnosis, since these tumors norma lly have
S-100 positive staining.
46,48,49
Surgical resection is considered curative, although it poses
challenges due to the tumor size and proximity to the anal sphincter, increasing the risk of
complications.
48
Case reports of perianal Kaposi sarcoma in HIV-positive MSM presenting as ulcers
were also described.
50
15.11 Anal Basal Cell Carcinoma
Basal cell carcinomas usually arise at the anal margin
51
and are extremely rare, comprising
0.2% of all anorectal tumors.
52
Larger tumors can extend to the anal canal.52No premalignant lesion has been identified. The sensation of a lump or an ulcer, bleeding, pain, and
perianal itching are the most common symptoms.
52
The typical appearance is a lesion/
mass with rolled edges and a central shallow ulceration.
39,52
An association between
perianal basal cell carcinoma and lesions at other sites was found in one-third of the cases,
suggesting the need for an examination of all cutaneous surfaces.
53
Immunohistochemical markers like diffuse Ber-EP4 expression are important differential features of these
lesions.
51
This tumor has a good prognosis52and has rarely metastasized.53Treatment modaliti es
depend on the location and extension, normally comprising wide local excision. Other
treatment modalities like abdominoperineal resection are rarely needed, except if a
deeper invasion is seen.
31
15.12 Secondary Tumors (Metastases) of the Anal Canal
Metastases to the anal canal are extremely rare, with few case reports in the literature.
Breast,
54
colon,55rectum,56lung,57and pancreto-biliar58malignancies were described to
metastasized to the anus. Anal metastasis can present simultaneously or in isolation from
the primary tumor.
58
The symptoms are often similar to an anal primary tumor.
54, 58
His-
tology and immunohistochemical staining are important for the differential diagnosis.
31, 54
196 ANORECTAL DISORDERS
References
1. Islami F, Ferlay J, Lortet-Tieulent J, Bray F, Jemal A. International trends in anal cancer incidence rates.
Int J Epidemiol. 2017;46:924–938.
2. Klas JV, Rothenberger DA, Wong WD, Madoff RD. Malignant tumors of the anal canal: the spectrum of
disease, treatment, and outcomes. Cancer. 1999;85:1686–1693.
3. Parkin DM. The global health burden of infection-associated cancers in the year 2002. Int J Cancer.
2006;118:3030–3044.
4. Machalek DA, Poynten M, Jin F, et al. Anal human papillomavirus infection and associated neoplastic
lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Oncol.
2012;13:487–500.
5. Moscicki AB, Darragh TM, Berry-Lawhorn JM, et al. Screening for anal cancer in women. J Low Genit
Tract Dis. 2015;19:S27–S42.
6. Ogunbiyi OA, Scholefield JH, Raftery AT, et al. Prevalence of anal human papillomavirus infection and
intraepithelial neoplasia in renal allograft recipients. Br J Surg. 1994;81:365–367.
7. Albuquerque A, Pessegueiro Miranda H, Lopes J, et al. Liver transplanted recipients have a higher
prevalence of anal squamous intraepithelial lesions. Br J Cancer. 2017;117:1761–1767.
8. Smittenaar CR, Petersen KA, Stewart K, Moitt N. Cancer incidence and mortality projections in the UK
until 2035. Br J Cancer. 2016;115:1147–1155.
9. Longo WE, Vernava 3rd AM, Wade TP, et al. Rare anal cancers in the U.S. veteran: patterns of disease
and results of treatment. Am Surg. 1995;61:495–500.
10. Franklin RA, Giri S, Valasareddy P, Lands LT, Martin MG. Comparative survival of patients with anal
adenocarcinoma, squamous cell carcinoma of the anus, and rectal adenocarcinoma. Clin Colorectal
Cancer. 2016;15:47–53.
11. Darragh TM, Colgan TJ, Cox JT, et al. The Lower Anogenital Squamous Terminology Standardization
Project for HPV-Associated Lesions: background and consensus recommendations from the College
of American Pathologists and the American Society for Colposcopy and Cervical Pathology. J Low Genit
Tract Dis. 2012;16:205–242 Review. Erratum in: J Low Genit Tract Dis. 2013; 17:368.
12. McCredie MR, Sharples KJ, Paul C, et al. Natural history of cervical neoplasia and risk of invasive
cancer in women with cervical intraepithelial neoplasia 3: a retrospective cohort study. Lancet Oncol.
2008;9:425–434.
13. Roberts JM, Thurloe JK. Comparison of the performance of anal cytology and cervical cytology as
screening tests. Sex Health. 2012;9:568–573.
14. Chin-Hong PV, Kwak EJ. AST infectious diseases Community of Practice. Human papillomavirus in
solid organ transplantation. Am J Transplant. 2013;13:189–200.
15. Aberg
JA,
Gallant JE, Ghanem KG, et al. Primary care guidelines for the management of persons
infected with HIV: 2013 update by the HIV medicine Association of the Infectious Diseases Society
of America. Clin Infect Dis. 2014;58:1–10.
16. Albuquerque A. High-resolution anoscopy: unchartered territory for gastroenterologists? World
J Gastrointest Endosc. 2015;7:1083–1087.
17. Brown SR, Skinner P, Tidy J, Smith JH, Sharp F, Hosie KB. Outcome after surgical resection for
high-grade anal intraepithelial neoplasia (Bowen’s disease). Br J Surg. 1999;86:1063–1066.
18. Goldstone SE, Johnstone AA, Moshier EL. Long-term outcome of ablation of anal high-grade squa-
mous intraepithelial lesions: recurrence and incidence of cancer. Dis Colon Rectum. 2014;57:316–323.
19. De Vuyst H, Clifford GM, Nascimento MC, Madeleine MM, Franceschi S. Prevalence and type distri-
bution of human papillomavirus in carcinoma and intraepithelial neoplasia of the vulva, vagina and
anus: a meta-analysis. Int J Cancer. 2009;124:1626–1636.
Chapter 15 • Anal Tumors 197
20. Guiguet M, Bou!e F, Cadranel J, Lang JM, Rosenthal E. Costagliola D; clinical epidemiology group of the
FHDH-ANRS CO4 cohort. Effect of immunodeficiency, HIV viral load, and antiretroviral therapy on
the risk of individual malignancies (FHDH-ANRS CO4): a prospective cohort study. Lancet Oncol.
2009;10:1152–1159.
21. Daling JR, WeissNS, Hislop TG, et al. Sexual practices, sexually transmitted diseases, and the incidence
of anal cancer. N Engl J Med. 1987;317:973–977.
22. Stier EA, Sebring MC, Mendez AE, Ba FS, Trimble DD, Chiao EY. Prevalence of anal human papilloma-
virus infection and anal HPV-related disorders in women: a systematic review. Am J Obstet Gynecol.
2015;213:278–309.
23. Saleem AM, Paulus JK, Shapter AP, Baxter NN, Roberts PL, Ricciardi R. Risk of anal cancer in a cohort
with human papillomavirus-related gynecologic neoplasm. Obstet Gynecol. 2011;117:643–649.
24. Adami J, G€abel H, Lindel€of B, et al. Cancer risk following organ transplantation: a nationwide cohort
study in Sweden. Br J Cancer. 2003;89:1221–1227.
25. Slesser AA, Bhangu A, Bower M, Goldin R, Tekkis PP. A systematic review of anal squamous cell
carcinoma in inflammatory bowel disease. Surg Oncol. 2013;22:230–237.
26. National Comprehensive Cancer Network (NCCN). Clinical Practical Guidelines on Anal Carcinoma.
https://www.tri-kobe.org/nccn/guideline/colorectal/english/anal.pdf; 2017 Access on 22 January
2018.
27.
Ajani JA, Winter KA, Gunderson LL, et al. US intergroup anal carcinoma trial: tumor diameter predicts
for colostomy. J Clin Oncol. 2009;27:1116–1121.
28. Albuquerque A, Sarmento J, Rios E, Macedo G. Gastrointestinal: anal Buschke Loewenstein tumor.
J Gastroenterol Hepatol. 2012;27:1537.
29. Basik M, Rodriguez-Bigas MA, Penetrante R, Petrelli NJ. Prognosis and recurrence patterns of anal ade-
nocarcinoma. Am J Surg. 1995;169:233–237.
30. Bosman FT, Carneiro F, Hruban RH, Theise ND, eds. WHO Classification of Tumours of the Digestive
System. Lyon: IARC Press; 2010.
31. Roy AC, Wattchow D, Astill D, et al. Uncommon anal neoplasms. Surg Oncol Clin N Am.
2017;26:143–161.
32. Beaugerie L, Carrat F, Nahon S, et al. High risk of anal and rectal cancer in patients with anal and/or
Perianal Crohn’s disease. Clin Gastroenterol Hepatol. 2017;
https://doi.org/10.1016/j.cgh.2017.11.041.
33.
Anwar S, Welbourn H, Hill J, Sebag-Montefiore D. Adenocarcinoma of the anal canal—a systematic
review. Colorectal Dis. 2013;15:1481–1488.
34. Pierie JP, Choudry U, Muzikansky A, Finkelstein DM, Ott MJ. Prognosis and management of extra-
mammary Paget’s disease and the association with secondary malignancies. J Am Coll Surg.
2003;196:45–50.
35. T
ulchinsky
H, Zmora O, Brazowski E, Goldman G, Rabau M. Extramammary Paget’s disease of the
perianal region. Colorectal Dis. 2004;6:206–209.
36. Karam A, Dorigo O. Increased risk and pattern of secondary malignancies in patients with invasive
extramammary Paget disease. Br J Dermatol. 2014;170:661–671.
37. Nardelli AA, Stafinski T, Menon D. Effectiveness of photodynamic therapy for mammary and extra-
mammary Paget’s disease: a state of the science review. BMC Dermatol. 2011;11:13.
38. Singer M, Mutch MG. Anal melanoma. Clin Colon Rectal Surg. 2006;19:78–87.
39. Quan SH. Anal and para-anal tumors. Surg Clin North Am. 1978;58:591–603.
40. Bello DM, Smyth E, Perez D, et al. Anal versus rectal melanoma: does site of origin predict outcome?
Dis Colon Rectum. 2013;56:150–157.
198 ANORECTAL DISORDERS
41. Khan M, Dirwees h A, Alvarez C, Conaway H, Moser R. Anal neuroendocrine tumor masquerading as
external hemorrhoids: a case report. Gastroenterol Res. 2017;10:56– 58.
42. Kobayashi H, Ueno H, Hashiguchi Y, et al. T1 neuroendocrine carcinoma of anal canal after transanal
resection for intramucosal adenocarcinoma. Jpn J Clin Oncol. 2006;36:325–328.
43. Steele RJ, Eremin O, Krajewski AS, Ritchie GL. Primary lymphoma of the anal canal presenting as peri-
anal suppuration. Br Med J (Clin Res Ed). 1985;291:311.
44. Morrison JG, Scharfenberg JC, Timmcke AE. Perianal lymphoma as a manifestation of the acquired
immune deficiency syndrome. Report of a case. Dis Colon Rectum. 1989;32:521–523.
45. Dasari BV, Khosraviani K, Irwin TS, Scott M. Perianal leiomyoma involving the anal sphincter. Ulster
Med J. 2007;76:173–174.
46. Miettinen M, Furlong M, Sarlomo-Rikala M, Burke A, Sobin LH, Lasota J. Gastrointestinal stromal
tumors, intramural leiomyomas, and leiomyosarcomas in the rectum and anus: a clinicopathologic,
immunohistochemical, and molecular genetic study of 144 cases. Am J Surg Pathol.
2001;25:1121–1133.
47. Nigri GR, Dente M, Valabrega S, et al. Gastrointestinal stromal tumor of the anal canal: an unusual
presentation. World J Surg Oncol. 2007;5:20.
48. Majbar A, Hrora A, Jahid A, Ahallat M, Raiss M. Perineal schwannoma. BMC Res Notes. 2016;9:304.
49. Pan J, Jing H, Tian X, Fan Z. Schwannoma with an uncommon anal location. Oncol Lett.
2014;8:1945–1946.
50. La Rosa L, Vaingurt M, Rub!en Miravalle O, et al. Perianal Kaposi’s sarcoma. A case report and a review
of the literature. Acta Gastroenterol Latinoam. 2013;43:39–43.
51. Patil DT, Goldblum JR, Billings SD. Clinicopathological analysis of basal cell carcinoma of the anal
region and its distinction from basaloid squamous cell carcinoma. Mod Pathol. 2013;26:1382–1389.
52. Nielsen OV, Jensen SL. Basal cell carcinoma of the anus-a clinical study of 34 cases. Br J Surg.
1981;68:856–857.
53. Paterson CA, Young-Fadok TM, Dozois RR. Basal cell carcinoma of the perianal region 20-year expe-
rience. Dis Colon Rectum. 1999;42:1200–1202.
54. Puglisi M, Varaldo E, Assalino M, Ansaldo G, Torre G, Borgonovo G. Anal metastasis from recurrent
breast lobular carcinoma: a case report. World J Gastroenterol. 2009;15:1388–1390.
55. Takahashi H, Ikeda M, Takemasa I, et al. Anal metastasis of colorectal carcinoma origin: implications
for diagnosis and treatment strategy. Dis Colon Rectum. 2011;54:472–481.
56. Sasaki
S,
Sugiyama M, Nakaji Y, et al. Anal metastasis of rectal cancer-adenocarcinoma of squamous
cells: a case report and literature review. Surg Case Rep. 2017;3:55.
57. Al-Tarakji M, Feilchenfeldt J, Haidar A, et al. Rare occurrence of metastasis from lung cancer to the
anus: case report and review of the literature. World J Surg Oncol. 2016;14:157.
58. Ejtehadi F, Chatzizacharias NA, Brais RJ, et al. Colonic and anal metastases from pancreato-biliary
malignancies. World J Gastroenterol. 2014;20:3693–3697.
Chapter 15 • Anal Tumors 199
16
Foreign Body and Anorectal Trauma
Kasaya Tantiphlachiva
DE P A R T ME N T O F S U R G E R Y , C H U L A L O N G K O R N UN I V E R S I T Y , B A N G K O K , THA I L A N D
16.1 Introduction
Anorect al foreign bo dy (FB) is one of the common presenting conditions of the patients
in the emergency depart ment (ED).
1
FB may be introduced into the rectum for sexual or
nonsex ual purposes and with or without the patient’s permission.
2
The most common
cause of anorectal F B results from anal insertion either by the patient or a sexual partner
for sexual stimulation.
3
Reported objects include vibrator, dildo, bot tle, metal object,
3
deodorant bottle,
4,5
shower head,6glass ball,7pen, toothpaste tube, Cuban cigar case,
drumstick,
5
and various vegetables and fruits (cucumber, apple,2carrot,8mandarin,
9
Irish potato,5and eggplant10). Nonsexual rectal FBs were fou nd in trauma, assault,
impale ment,
2,6,11
concea lment for drug traffick ing or in self-relief of constipation, pru-
ritus ani, or hemorrhoids.
6,11
There are report s of prisoners hiding weapons in their rectum and psychiatric patients purposely hiding sharp objects in order to injure the
physician who performs the rectal examination.
11
Infrequently, FBs result from impac-
tion of the ing ested object,
12
such as phytobezoar (pumpkin seed,13acerola cherry,
14
Baccaurea macrocarpa [tropical fruit] seed15), chicken/ bird bone,
16,17
and metallic cur-
tain hook.
18
These objects have been observ ed in the elderly, children, or persons with
mental illness.
2,14,15
Erosion or penetration of objects from the adjacent pelvic organs
could present as recta l FB.
19
Vice versa, impalement from rectum co uld present as FB
in urinary bladder.
20
Table 16.1 demonstrates the types of rectal FB acc ording to the rea-
sons for their presence in the rectum. The approach to anorectal FB without a history of
multi-system trauma will be discussed first. The trauma scenario where multi-system
injury is suspecte d is discussed in the following section.
16.2 Epidemiology
The true incidence of anorectal FB is underreported
11
but is increasing. It is an important
problem in the emergency and surgical departments.
6,22
It is more prevalent in males with
a male:female ratio of 28:1.
1
There is bimodal age distribution.23The first peak is in males
aged between 20 and 40 years old,
1
representing anal eroticism in young to middle-aged
homosexual men.
6,23
The second peak, in the 60s, is due to self-treatment of various
conditions, such as prostatic massage and the attempt to break down fecal impaction.
23
Anorectal Disorders. https://doi.org/10.1016/B978-0-12-815346-8.00016-3
© 2019 Elsevier Inc. All rights reserved.
201
In females, the peak age range was 80–89years. Greater involvement of mental illness was
found in females compared to males (2.7% vs 8.2%, P ¼.007).
24
Common causes were
impaction of the ingested objects, such as fish bone
24
and chicken bone.25Seasonal var-
iation in the incidence is observed but data are still limited.
26
16.3 Clinical Assessment
16.3.1 History Taking
Most patients with retained sexual objects are embarrassed and reluctant to give details
about their problems.
2
The presentation is usually delayed and with an obscu re and dis-
torted history.
6
Complaints are usually nonspecific, including rectal pain, rectal fulln ess,
rectal bleeding, abdominal pain or discomfort, pelvic pain, tenesmus,
6
constipation,
2,11
rectal mucous leakage,2and difficulty in micturition.11Patients often visit the hospital several hours to days after unsuccessful attempts by themselves at removal
2
or they may pre-
sent with delayed symptoms of bleeding, perforation, or incontinence.
2
It is important to
provide emotional and psychological support during the inter view, and information
regarding the character of the object(s), timing of event, and the possible trauma from
attempted removal should be obtained.
2
16.3.2 Physical Examination
The initial assessment is to look for signs of bowel perforation, obstruction, or local rectal
injury, such as fever, tachycardia, hypotension, abdominal distension, and signs of peritonitis
27
In the absence of peritonitis, FB may be palpable during abdominal examina-
tion.
27
Digital rectal examination (DRE) is a useful and important step. However, sharp
or dangerous objects should be excluded.
12,27
In suspected case, plain abdominal X-ray
may be obtained prior to DRE. Anal inspection may reveal signs of anal receptive intercourse.
28
External laceration, fissures, hemorrhoids, frank blood, and anal sphincter tone
should be noted.
6,27,28
Decreased sphincter tone may result from direct anal sphincter
injury and increased sphincter tone may result from muscular spasm due to pain if the
sphincter is intact.
2,27
Documentation of resting and squeeze tone and sensation is impor-
tant.
2
Position and mobility of the object should be noted.27A low-lying FB is palpable
Table 16.1 Type of Rectal Foreign Body
2,10,21
Reasons Examples
1. Anal eroticism purpose
Vibrator, bottle, fruits, vegetables
2. Diagnostic and treatment purpose Thermometer, tip of enema bottle, surgical needle
3. Violence, assault, impalement Broomstick, wooden stake, incense stick
4. Accident Tree branch, metal cross bar
5. Ingested and impact in rectum Fish bone, chicken bone, toothpick
6. Erosion from adjacent organ Intrauterine device, pelvic mesh
7. Objects concealment Body packer, body pusher
202 ANORECTAL DISORDERS
during DRE and is located distal to the rectosigmoid junction. A high-lying FB is not palpable during DRE and is located above rectosigmoid junction or beyond the sacral curve.
1
16.3.3 Radiologic Evaluation
Plain abdominal radiographs are indicated in almost all cases with rectal FB.
12
Exceptions
are those which are clinically indicated for abdominal computed tomography (CT) scan.
12
Lateral and anteroposterior plain abdominal and pelvic films should be obtained to identify the number, size, shape, location, and orientation of the FB.
2,11,12,28
Combined with
chest X-ray/lateral decubitus abdominal X-ray,
27
pneumoperitoneum and signs of colonic
obstruction should be looked for.
2,11,12
Air-filled, radiolucent objects may appear as a gas
pattern in the shape of the FB. Rectal contrast may be needed to outline these objects.
12
Diagnostic accuracy of plain radiograph is limited with a sensitivity for detecting free-air
of 78%–96%.
27
CT scan is indicated to look for nonradiopaque objects, such as fish bone, plastic, candle, thin glass objects, or organic material, which are not sufficiently visualized by plain
radiography
6,27
especially in obese patient.27Shape, size location, and depth of the
impacted FB and the surrounding tissue can be visualized.
27
An intravenous contrast
agent is used for additional information when FB-related complications including
colorectal perforation, intestinal obstruction, hemorrhage, abscess, or fistula are suspected.
6,11,27
Sensitivity of 90%–100% and specificity of 93.7%–100% were reported.
27
16.4 Management
For FB that can be felt by DRE or local ized by imaging, without signs of peritonitis, transanal removal under anesthesia could be attempted.
1,12
If complication (perforation,
bleeding, obstruction) presents, a colorectal or general surgeon should be consulted.
11
Fluid resuscitation, intravenous broad-spectrum antibiotics, and preoperative
preparation should be initiated.
2
In such cases, an abdominal and pelvic CT scan may
be required for additional information about the character and position of both the
object itself and the occurring complication . In noncomplicated cases, the use of enema
alone and the allowance of auto-expulsion of the FB has been reported in pediatric
patients.
14,29
However, when patients have attempted to remove the rectal FBs themselves
this usually causes mucosal edema, muscular spasm
6
and this may result in the FB migrat-
ing more proximally.
4
Thus these FBs usually need some form of maneuver to allow
retrieval.
16.4.1 Transanal Removal
When complication is not suspected, that is, there is no evidence of peritonitis or severe
bleeding and the patient is clinically and hemodynamically stable, transanal removal is
the first-line treatment in low-lying FBs that are within the reach of DRE.
2,6,27
Some
authors advocated transanal removal in the ED.
27,30
However, in a busy ED environment
Chapter 16 • Foreign Body and Anorectal Trauma 203
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