What is the next step in care for a patient who ingested a foreign body (FB), confirmed by CT scan to be in the rectum with fecal attenuation at the terminal ileum, and has not passed the object despite treatment with magnesium citrate (mag citrate)?

Management of Retained Methamphetamine Baggy in Rectum

Endoscopic removal under anesthesia is urgently needed for this patient with a retained drug package in the rectum that has not passed despite laxative treatment. 1

Clinical Assessment and Risk Evaluation

The patient has several concerning features:

• Ingested methamphetamine baggy 11 days ago
• CT scan confirmed foreign body in rectum with fecal attenuation at terminal ileum
• Follow-up X-ray 3 days later shows foreign body still present
• Failed passage despite magnesium citrate administration
• No bowel movements reported by patient

This represents a high-risk situation for several reasons:

• Drug package retention poses risk of rupture and life-threatening toxicity
• Prolonged retention (11+ days) increases risk of complications
• Terminal ileum attenuation suggests possible partial obstruction
• Failed response to laxative therapy indicates need for intervention

Management Approach

Immediate Next Steps

1. Urgent surgical consultation for endoscopic removal under anesthesia

   • This patient requires prompt intervention due to:
     • Failed conservative management with laxatives 1
     • Prolonged retention of a potentially toxic substance 1, 2
     • Risk of drug package rupture with life-threatening consequences 1

2. Avoid any maneuvers that could disrupt the drug package

   • The World Journal of Emergency Surgery guidelines specifically warn against any maneuvers that might rupture drug packages 1
   • Endoscopic retrieval must be performed with extreme caution in cases of drug concealment 1

Important Considerations

• Drug package precautions: This case requires special handling as a "body packer" scenario, with extreme caution to prevent package rupture 1
• Complete GI tract evaluation: When drug packages are detected in the anorectal region, a complete survey of the GI tract is required as many are swallowed rather than inserted retrograde 1
• Anesthesia benefits: General anesthesia or conscious sedation will help relax the patient, reduce anal sphincter spasm, improve visualization, and increase chances of successful extraction 1

Procedural Recommendations

1. Anesthesia approach:

   • General anesthesia or deep sedation is recommended to facilitate complete relaxation 1
   • This relaxation may be sufficient to allow successful extraction that was previously impossible 1

2. Extraction technique:

   • Careful endoscopic visualization and extraction under direct visualization 1
   • Avoid excessive manipulation that could rupture the package 1
   • Post-extraction evaluation of bowel wall status is essential 1, 2

3. If endoscopic removal fails:

   • Consider a surgical approach using a "step-up" methodology 1
   • Laparoscopic-assisted technique with gentle downward milking of the foreign body may be required 1

Monitoring and Follow-up

• Close monitoring for signs of methamphetamine toxicity during and after the procedure
• Post-extraction imaging to ensure complete removal of all foreign material
• Evaluation for any bowel wall damage or complications 1, 2

Pitfalls to Avoid

• Do not attempt aggressive manual extraction without proper visualization and anesthesia
• Do not administer additional laxatives, as this has already failed and may increase risk of package rupture
• Do not delay intervention, as prolonged retention increases risk of complications 2
• Do not use techniques that might apply excessive pressure to the drug package 1