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A foreign body between the rectum and bladder
A FOREIGN BODY BETWEEN THE RECTUM AND BLADDER CASE REPORT GREGORY L. ROBILLARD, M.D., CHARLES GOLDMAN, M.D. Attending Surgeon, Brooklyn Cancer Institute and AssociateAttending Surgeon, Brooklyn Cancer Norwegian Hospital Institute AND FRANCIS 0. OSTERHUS, M.D. Associate Surgeon, Genito-Urinary Department, Norwegian Hospital BROOKLYN, NEW YORK OREIGN.bodies are frequentIy found greater number which were never reported, in the intestina1 tract and their presbut these six reports are of specia1 interest. Smith’ pubIished a report of a darning ence is expIained in one of five ways: needIe found in the appendix by Mr. (I) They were swaIIowed; (2) they were introduced through the anus; (3) they Christopher Martin which was shown were formed within the intestine; (4) they before the MidIand MedicaI Society, November 12, rgrg. AIthough the patient entered by some pathoIogic process from another organ, and (3) they got into the had no expIanation for the presence of the intestina1 tract as a resuIt of a vioIent needIe, the symptoms of which she cominjury. pIained during the preceding twenty years indicated the course of the needIe through There are many reports in the Iiterature of foreign bodies swaIIowed intentionaIIy, the aIimentary cana1. In 1897, she suffered for the most part by insane persons, or from indigestion and a diagnosis of gastritis accidentaIIy, usuaIIy with the knowledge, was made. In IgoT, the patient had a vioIent attack of hematemesis, vomiting but often without the knowIedge, of the patient. When the object is swaIIowed about two pints of bIood and she nearIy without the patient’s being aware of so died. SubsequentIy, she suffered from occadoing, the symptoms of which he compIains siona1 recurrences of epigastric pain. In are varied; and these patients present JuIy, rgr 3, about a month before the needIe was found, she had an attack of pain in the great difficuIty in diagnosing the source of their troubIe. Symptoms vary with the region of the duodenum. A medica man nature of the object swaIIowed and with whom she consuIted thought the pain. the portion of the intestine in which the might be due to appendicitis. She has had no recurrence of symptoms since the reobject is arrested. Many of the objects, even though sharp, pass through the aIi- mova1 of the needIe. Akers2 reports the case of a man who had mentary tract without causing any sympa pin in the rectum for thirty years. whiIe others cause sIight pain, toms, intense pain, serious injury to the gut, re- Symptoms of pain of a pricking character in the recta1 region on sitting down, consuItant peritonitis and death. SwaIIowed stant desire to defecate, great pain on objects are most often arrested in the esophagus, pyIoric orifice, duodenum, iIeo- defecation with the stooIs smaI1, pipe-Iike cecaI vaIve, somewhere in the ffexures of and streaked with bIood, had been present for more than thirty years. The pin was the Iarge bowe1, and Iast and most frefound just within the anus above the quentIy in the anus. muscIes. After the pin was reIn a cursory search of the Iiterature six sphincter moved a11 symptoms subsided. The patient interesting cases of a sharp object in the was unabIe to account for the presence of intestina1 cana were noted. There are many more in the Iiterature and a stiI1 the pin. 419
F
420
American Journal of Surgery
Robillard
et al.-Foreign
Carp3 in a review of forty-eight proved cases of foreign body in the intestine, cites the case of a chiId who swaIIowed a pin,
FIG. I. X-ray before proctoscopy showing the pin at the lcvcl of the lowest sacral vertebra.
which caused death from peritonitis. He found that a sharp object took from two days to three weeks to go through the intestina1 tract, and says that in order of :
‘_
:
FIG. 3. The ordinary pin is about ztg cm. whiIe this pin is stightly over 3 cm. in length.
frequency the rectum, cecum and sigmoid offer the best anatomica sites for the arrest He concIudes that a of foreign bodies. foreign body may travel from the intestine into another organ, or into the peritoneal cavity and from there into muscIe planes with IittIe or no symptoms. a case of a fish-bone David 4 reports
Bodies
SEPTEMBER, I1944
which was swalIowed and was pass ;ed through the urethra. Cordier” reports the case of a boy, sixte :en
FIG. 2. X-ray taken after proctoscopy showing pin in a more transverse position at the level of the Iowest sacral vertebra. The pin is sIightly bent.
years oId, who for two or three years compIained of symptoms pointing to the bIadder. He had pain in the right inguina1 region and great tenderness extending to the median Iine, which at first was diagnosed as typhoid fever. On passage of a sound into the bIadder a stone was feIt. At operation two stones were found, one about the size of a pigeon’s egg and a second suspended from the fundus by a short veil-pin protruding into the btadder. A feca1 concretion was attached to the head of the pin. MueIIer,6 in a report before the PhiIadeIphia Academy of Surgery, teIIs of a thirtyfour year oId femaIe who swaIIowed a pin which was removed nine years Iater. She compIained of pain in the Ioin and in the right iIiac fossa, together with frequency of urination. An x-ray reveaIed a stone in the Iower pole of the right kidney and a pin at the IeveI of the sacro-iIiac joint, Iying in the course of the ureter.. RemovaI of
NEW SERIESVOL.LXV, No. 3
the kidney symptoms.
stone
RobiIIard
and
CASE
the
pin
aIIayed
et aI.-Foreign a11
REPORT
The case we are presenting was a male, A. H., aged twenty-six years, admitted to the Norwegian Hospital on November 20, 1942, with a diagnosis of foreign body in the rectovesical space. The chief compIaint was pain in the low back of a week’s duration. The pain was increased on sitting or walking. The past history and famiIy history were irrelevant. On November Isth, while working in a shipyard, the patient felt pain in the Iower back radiating to the coccyx. X-ray revealed a foreign body of the shape and size of a Iong pin, Iying in the middIe of the Iower pelvis.. (Fig. I.) PhysicaI examination reveaIed the bIood pressure to be 120/80. The genera1 appearance was that of a young, adult male, we11 deveIoped and apparentIy in good health. The pupiIs reacted to Iight and accommodation. The tonsiIs were normal. The heart, Iungs and abdomen reveaIed nothing abnorma1. The genitourinary system showed nothing of note. On November 20, 1942, a proctoscopic examination by one of us (c. G.) reveaIed three uIcers, varying in size from $i to 3/4 cm. just, beIow the IeveI of the rectosigmoid, which bled sIightIy on touching with an applicator. There were some feces in the rectum which were removed by enema. A sharp object which was between the bIadder and rectum was feIt with the end of the proctoscope, anterior to and outside the rectum. Because of the uncertainty of the exact position of the object with reference to the peritonea1 refIection, it was thought best not to attempt its remova through the rectum. After finishing the proctoscopic examination another x-ray revealed the object stiI1 present, anterior to the rectum, with its position slightly changed. (Fig. 2.) Cystoscopic examination by one of us (F. 0.) faiIed to revea1 the pin in the bIadder. On November qrd, an expIoratory Iaparotomy was performed. The bIadder was distended with fluid through a catheter, which
Bodies
American Journal of St,rgery
42 I
was permitted to remain in silu. A midIine incision was made extending from beIow the umbihcus to just above the symphisis. The rectae mu&es were separated, the peritoneum ,opened and the peIvic structures inspected. To the Ieft of the midline, on the posteroIatera1 surface of the urinary bladder, a dimpIed area with injected edges was noted running in a transverse direction. PaIpation of this area reveaIed the presence of the pin. An eIIiptica1 incision was made in the peritoneum, enclosing the pin, and the pin with the surrounding tissue was excised. The bladder was then repaired with No. oo chromic, pursestring suture, and the peritoneum cIosed with No. oo pIain gut. The abdomen was cIosed with bIack silk. (Fig. 3.) The patient was discharged from the hospita1 on December 4, 1942, symptom free. He has since been inducted into the armed forces. SUMMARY I.
SeveraI interesting cases of the presof a sharp object in the intestina1 are noted. 2. A case is reported of a young, aduIt maIe, in whom the x-ray showed the unexpIained presence of a Iong pin, Iying between the bIadder and rectum. 3. The authors are unabIe to expIain the symptoms of which the patient compIained by the presence of the pin in the position in which it was found.
ence tract
REFERENCES
,.
HEYWOOD. A needle in the alimentary canal. I : 8 I, 1920. 2. AKERS, W. D. Pin in the rectum for thirty years. Lancet, 2: 690, 1898. bodies in the intestines. 3. CARP, RALPH. Foreign Ann. Surg., 85: 575-591, 1927. 4. DAVID, I. An errant fishbone. Brit. M. J., I : 166, SMITH,
Brit. M. J.,
1918.
5. CORDIER, A. H. Some unusua1 surgical cases. J. Clin. Med., 14: 1001, 1907. 6. MUELLER, GEORGE P. Foreign body removed from abdomen nine years after it had been swallowed. Ann. Surg., 67: 380-382, 1918.
F
420
American Journal of Surgery
Robillard
et al.-Foreign
Carp3 in a review of forty-eight proved cases of foreign body in the intestine, cites the case of a chiId who swaIIowed a pin,
FIG. I. X-ray before proctoscopy showing the pin at the lcvcl of the lowest sacral vertebra.
which caused death from peritonitis. He found that a sharp object took from two days to three weeks to go through the intestina1 tract, and says that in order of :
‘_
:
FIG. 3. The ordinary pin is about ztg cm. whiIe this pin is stightly over 3 cm. in length.
frequency the rectum, cecum and sigmoid offer the best anatomica sites for the arrest He concIudes that a of foreign bodies. foreign body may travel from the intestine into another organ, or into the peritoneal cavity and from there into muscIe planes with IittIe or no symptoms. a case of a fish-bone David 4 reports
Bodies
SEPTEMBER, I1944
which was swalIowed and was pass ;ed through the urethra. Cordier” reports the case of a boy, sixte :en
FIG. 2. X-ray taken after proctoscopy showing pin in a more transverse position at the level of the Iowest sacral vertebra. The pin is sIightly bent.
years oId, who for two or three years compIained of symptoms pointing to the bIadder. He had pain in the right inguina1 region and great tenderness extending to the median Iine, which at first was diagnosed as typhoid fever. On passage of a sound into the bIadder a stone was feIt. At operation two stones were found, one about the size of a pigeon’s egg and a second suspended from the fundus by a short veil-pin protruding into the btadder. A feca1 concretion was attached to the head of the pin. MueIIer,6 in a report before the PhiIadeIphia Academy of Surgery, teIIs of a thirtyfour year oId femaIe who swaIIowed a pin which was removed nine years Iater. She compIained of pain in the Ioin and in the right iIiac fossa, together with frequency of urination. An x-ray reveaIed a stone in the Iower pole of the right kidney and a pin at the IeveI of the sacro-iIiac joint, Iying in the course of the ureter.. RemovaI of
NEW SERIESVOL.LXV, No. 3
the kidney symptoms.
stone
RobiIIard
and
CASE
the
pin
aIIayed
et aI.-Foreign a11
REPORT
The case we are presenting was a male, A. H., aged twenty-six years, admitted to the Norwegian Hospital on November 20, 1942, with a diagnosis of foreign body in the rectovesical space. The chief compIaint was pain in the low back of a week’s duration. The pain was increased on sitting or walking. The past history and famiIy history were irrelevant. On November Isth, while working in a shipyard, the patient felt pain in the Iower back radiating to the coccyx. X-ray revealed a foreign body of the shape and size of a Iong pin, Iying in the middIe of the Iower pelvis.. (Fig. I.) PhysicaI examination reveaIed the bIood pressure to be 120/80. The genera1 appearance was that of a young, adult male, we11 deveIoped and apparentIy in good health. The pupiIs reacted to Iight and accommodation. The tonsiIs were normal. The heart, Iungs and abdomen reveaIed nothing abnorma1. The genitourinary system showed nothing of note. On November 20, 1942, a proctoscopic examination by one of us (c. G.) reveaIed three uIcers, varying in size from $i to 3/4 cm. just, beIow the IeveI of the rectosigmoid, which bled sIightIy on touching with an applicator. There were some feces in the rectum which were removed by enema. A sharp object which was between the bIadder and rectum was feIt with the end of the proctoscope, anterior to and outside the rectum. Because of the uncertainty of the exact position of the object with reference to the peritonea1 refIection, it was thought best not to attempt its remova through the rectum. After finishing the proctoscopic examination another x-ray revealed the object stiI1 present, anterior to the rectum, with its position slightly changed. (Fig. 2.) Cystoscopic examination by one of us (F. 0.) faiIed to revea1 the pin in the bIadder. On November qrd, an expIoratory Iaparotomy was performed. The bIadder was distended with fluid through a catheter, which
Bodies
American Journal of St,rgery
42 I
was permitted to remain in silu. A midIine incision was made extending from beIow the umbihcus to just above the symphisis. The rectae mu&es were separated, the peritoneum ,opened and the peIvic structures inspected. To the Ieft of the midline, on the posteroIatera1 surface of the urinary bladder, a dimpIed area with injected edges was noted running in a transverse direction. PaIpation of this area reveaIed the presence of the pin. An eIIiptica1 incision was made in the peritoneum, enclosing the pin, and the pin with the surrounding tissue was excised. The bladder was then repaired with No. oo chromic, pursestring suture, and the peritoneum cIosed with No. oo pIain gut. The abdomen was cIosed with bIack silk. (Fig. 3.) The patient was discharged from the hospita1 on December 4, 1942, symptom free. He has since been inducted into the armed forces. SUMMARY I.
SeveraI interesting cases of the presof a sharp object in the intestina1 are noted. 2. A case is reported of a young, aduIt maIe, in whom the x-ray showed the unexpIained presence of a Iong pin, Iying between the bIadder and rectum. 3. The authors are unabIe to expIain the symptoms of which the patient compIained by the presence of the pin in the position in which it was found.
ence tract
REFERENCES
,.
HEYWOOD. A needle in the alimentary canal. I : 8 I, 1920. 2. AKERS, W. D. Pin in the rectum for thirty years. Lancet, 2: 690, 1898. bodies in the intestines. 3. CARP, RALPH. Foreign Ann. Surg., 85: 575-591, 1927. 4. DAVID, I. An errant fishbone. Brit. M. J., I : 166, SMITH,
Brit. M. J.,
1918.
5. CORDIER, A. H. Some unusua1 surgical cases. J. Clin. Med., 14: 1001, 1907. 6. MUELLER, GEORGE P. Foreign body removed from abdomen nine years after it had been swallowed. Ann. Surg., 67: 380-382, 1918.