Letters to Editor

When the early phase is over and the patient presents with foreign body is swallowed, passes through the gastrointestinal upper abdominal pain, a history of recent or remote penetrating tract and is held up in rectum. Many endoscopic and surgical thoracoabdominal trauma on the left side should give rise to clinical techniques to remove rectal foreign bodies have been described suspicion of a delayed diaphragmatic hernia complication like in the literature and the reported variety of foreign bodies is incarceration or strangulation of the herniated stomach.[3] Proper as large as the number of techniques used to remove them.[1,2] radiological examinations will help in diagnosis.[2] Chest X-ray is the initial radiologic investigation, which reveals absence of A 40-year-old male consulted the emergency department for fundic gas in its normal position, elevation of the hemidiaphragm sexual aggression. The patient said that he had been assaulted with its absent sharp outline and coiled nasogastric tube located by two intoxicated individuals. Tying him up, they had conducted within the left hemithorax. Oral administration of barium or a sexual assault by forced introduction of a foreign body in the water-soluble contrast may enhance the detection of bowel rectum. The patient had consulted 2 hours after the attack. At within the chest.[2] MDCT is the most appropriate second-line examination, vital signs were normal. Abdomen was soft. Foreign study.[2,4] Multiplanar reformations of high spatial resolution body was palpable on rectal examination. X-ray of the pelvis improve the accuracy of CT in demonstrating diaphragmatic showed the glass in lower abdomen and pelvis [Figure 1]. defects and hernias. The demonstration of conclusive radiologic findings of collar sign as a constriction of hollow viscus at the The manual removal by holding the base of the glass was diaphragmatic defect and dependent viscera sign as abdominal impossible and snares repeatedly slipped due to mucous coating organs set against posterior ribs enhances the diagnosis of post- the surface. Moreover, the glass could not be manipulated. traumatic diaphragmatic hernia.[4] The management strategy includes hernia reduction, pleural drainage and repair of the After reassurance and administration of IV analgesic, in diaphragmatic defect.[3] lithotomy position several uni- and bi-manual extractions using obstetrics forceps had been attempted with no success and had even led to a partial fracture of the glass, making the transanal Nisar Ahmad Wani, Tasleem Lone Kosar, extraction extremely dangerous. Endoscopy and laparoscopy Asrar Ahmad1, Mohammad Yusuf2 were not available in emergency. Then we proceeded to a general anesthetic and a Midline LAPAROTOMY was performed. We Departments of Radiodiagnosis and Imaging, 1Cardiovascular Thoracic gradually tipped the glass to the sigmoid loop before making Surgery and 2Gastroenterology, Sher-I-Kashmir Institute of Medical a short colostomy to extract the glass from sigmoid colon. A Sciences (SKIMS), Srinagar, J & K, India colostomy at the left iliac fossa was made. The post operative DOI: 10.4103/0974-2700.66539 curse was uneventful and the patient left the hospital on the fourth day. The intestinal continuity was restored 3 months later. REFERENCE Reports of foreign body within the rectum are uncommon in 1. Madden MR, Paull DE, Finkelstein JL, Goodwin CW, Marzulli V, Yurt RW, Africa, and the majority of case series are reported from Eastern . Occult diaphragmatic injury from stab wounds to the lower chest and et al [1-6] [1,2] abdomen. J Trauma 1989;29:292-8. Europe. Males are commonly affected. The age group is 16–80 years.[1] However, there is a bimodal age distribution, 2. Dwivedi S, Banode P, Gharde P, Bhatt M, Johrapurkar SR. Treating traumatic injuries of the diaphragm. J Emerg Trauma Shock 2010;3:173-6. observed in the twenties for anal erotism or forced introduction 3. Abboud B, Tabet G, Bou Jaoude J, Sleilaty G. Gastric incarceration and perforation following posttraumatic diaphragmatic hernia: case report and review of the literature. J Med Liban 2007;55:104-7. 4. Bergin D, Ennis R, Keogh C, Fenlon HM, Murray JG. The “dependent viscera” sign in CT diagnosis of blunt traumatic diaphragmatic rupture. AJR Am J Roentgenol 2001;177:1137-40. 5. Powell BS, Magnotti LJ, Schroeppel TJ, Finnell CW, Savage SA, Fischer PE, et al. Diagnostic laparoscopy for the evaluation of occult diaphragmatic injury following penetrating thoracoabdominal trauma. Injury 2008;39:530-4.

Foreign body of the rectum: An unusual case

Sir, Foreign body within the rectum occurs infrequently. Majority Figure 1: X-ray pelvis showing the glass in lower abdomen and of objects are introduced through anus; however, sometimes a pelvis Letters to Editor through anus, and in the sixties mainly for prostatic massage and REFERENCES breaking fecal impactions. 1. Biriukov IuV, Volkov OV, An VK, Borisov EIu, Dodina AN. Treatment The foreign bodies commonly reported are plastic or glass of patients with foreign body rectum. Khirurgiia (Mosk) 2000; bottles, cucumbers, carrots, wooden, or rubber objects.[2] Other 7:41-3. objects reported are bulb, tube light, axe handle, broomstick, 2. Petrolito E, Bracchitta S, Calabrese C, Riolo G, Donati A, Pecorella vibrators, etc. The object length varies between 6 and 15 cm, and G. Foreign bodies and injuries of the rectum. Minerva Chir 1989;44: 867-71. larger objects were more prone for complications.[2] 3. Gaponov VV. Foreign bodies in the rectum and colon. Klin Khir 1992;2:37-40. Abdominal and rectal pains and bleeding per rectum are the common presenting symptoms. Per rectal examination is the 4. Akhtar MA, Arora PK. Case of unusual foreign body in the rectum. Saudi J Gastroenterol 2009;15:131-2. cornerstone in the diagnosis, but it should be performed after X-ray of the abdomen to prevent accidental injury to the surgeon 5. Lake JP, Essani R, Petrone P, Kaiser AM, Asensio J, Beart RW Jr. [4] Management of retained colorectal foreign bodies: predictors of operative from sharp objects. intervention. Dis Colon Rectum 2004;47:1694-8. 6. Koornstra JJ, Weersma RK. Management of rectal foreign bodies: The first step in the evaluation is that one should always be aware Description of a new technique and clinical practice guidelines. World J of the possibility of a large bowel perforation and perform Gastroenterol 2008;14:4403-6. radiological investigations. Plain abdominal radiography or water soluble contrast enemas may be helpful. An abdominal X-ray will also provide information on the localization of the foreign body, whether it is below or above the rectosigmoid Unusual malignant cause junction. If perforation of the bowel has occurred, immediate laparotomy is warranted. If there are no signs of perforation, of adult intussusception: several management approaches can be tried.

First, digital removal of the object should be attempted, if Stromal tumor of the necessary, with the patient at different positions. If this approach fails, one can try bimanual manipulation, as we tried in our patient. small bowel The next step is the insertion of an endoscope with subsequent attempts to grasp the foreign body with regular endoscopy Sir, accessories like polypectomy snares. When this fails, it may be Gastrointestinal stromal tumors (GISTs) are rare and specific helpful to use devices that can be inflated in the rectosigmoid, tumors of the gastrointestinal system. They are commonly such as a Foley catheter or an achalasia balloon. Such a device located in the stomach and small bowel. Intussusception prevents a vacuum that might develop upon extraction of the and obstruction is a very uncommon presentation of these foreign body and may also be directly used to remove the object.[5] lesions because of their tendency to grow in an extraluminal fashion. Laparotomy is only required in impacted foreign body (as in our patient) and or with perforation peritonitis. Even with A 59-year-old female patient was admitted to the emergency laparotomy, the aim is transanal removal and closure of room with a 6-month history of intermittent attacks of perforation with diversion colostomy. Post retrieval colonoscopy abdominal distension and pain, obstipation, and new onset of is mandatory to rule out colorectal injury.[6] vomiting. Physical examination revealed abdominal distension and hyperactive bowel sounds. No significant weight loss or In conclusion, many techniques are available for the extraction of palpable mass was identified. Computed tomographic scan rectal foreign bodies. If possible, patients should be treated with showed the “target” sign of intussusception. Laparotomy minimally invasive techniques. When these techniques are not revealed ileoileal intussusception secondary to intramural mass available or cannot extract the foreign body, surgery is required. in the terminal ileum, located 70 cm proximal to the ileocecal valve. Ileoileal anastomosis was performed after resection of the tumoral segment. No complication occurred in the early Y Narjis, K Rabbani, K Hakkou, T post-operative period. Pathological investigation confirmed that Aboulhassan1, A Louzi, R Benelkhayat, the neoplasm was a small bowel GIST. Immunohistochemical studies showed positive stains for protein S100, vimentin and B Finech, A EL Idrissi Dafali c-kit and CD 34 [Figure 1]. Department of General Surgery, 1Department of Anesthesia Reanimation, CHU Mohammed VI, Cadi Ayyad University, GISTs are a group of rare tumors of the digestive tract Marrakech, Morocco that constitute about 1% of all gastrointestinal cancers;[1] in DOI: 10.4103/0974-2700.66542 20–30% of the patients, it has been seen in the small intestines. Copyright of Journal of Emergencies, Trauma & Shock is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.