What is the management for a patient with a foreign body, specifically a light bulb, stuck in the rectum?

Management of Rectal Foreign Body (Light Bulb)

For a hemodynamically stable patient with a light bulb in the rectum and no signs of perforation, obtain anteroposterior and lateral X-rays first, then attempt bedside transanal extraction under anesthesia, escalating to endoscopy or surgery only if this fails. 1

Initial Assessment

Obtain focused history and complete physical examination to assess for peritonitis, hemodynamic instability (tachycardia, hypotension, fever), and signs of perforation. 1

• Delay digital rectal examination until after X-ray acquisition to prevent accidental injury from sharp edges of broken glass if the bulb has fractured. 1, 2
• Assess external perianal area for abrasions, bruising, and sphincter status—document thoroughly as this may be relevant for assault investigation. 1
• Maintain professionalism; patients often delay presentation due to embarrassment and may not initially disclose the foreign body as their chief complaint (occurs in up to 20% of cases). 1

Imaging

Obtain anteroposterior and lateral plain X-rays of chest, abdomen, and pelvis to identify the light bulb's position, size, shape, location, and detect pneumoperitoneum. 1

• Plain radiographs are sufficient for radiopaque objects like light bulbs and can detect complications. 1, 3
• Do not routinely order laboratory tests if there are no signs of perforation or peritonitis. 1
• If perforation is suspected (peritonitis, pneumoperitoneum), obtain CBC, serum creatinine, and inflammatory markers (CRP, procalcitonin, lactates) before surgery. 1

Treatment Algorithm

If Hemodynamically Unstable or Signs of Perforation/Peritonitis:

Do NOT attempt transanal extraction—proceed immediately to emergent laparotomy with damage control surgery. 1

• Resuscitate with IV fluids and broad-spectrum antibiotics before surgery. 1

If Hemodynamically Stable Without Perforation:

Step 1: Bedside Transanal Extraction

Attempt bedside transanal extraction as first-line therapy for low-lying objects (light bulbs typically lodge in the rectum). 1

• Use anesthesia (pudendal nerve block, spinal anesthesia, IV conscious sedation, or general anesthesia) to relax the anal sphincter, reduce spasm, improve visualization, and increase success rates (60-75% success with transanal extraction). 1
• Multiple instruments can grasp or scoop the object, but no single technique is superior. 1
• Critical pitfall with light bulbs: The smooth, rounded shape and potential for vacuum suction make extraction challenging. Grasping hard objects like glass bulbs can cause upward migration toward the sigmoid or fracture the bulb, creating sharp edges. 4
• Consider creating a small hole in the bulb base to break the vacuum seal if safe to do so, facilitating removal. 4

Step 2: Extraction Under General Anesthesia

If bedside extraction fails, attempt transanal extraction under general anesthesia with complete muscular relaxation, which may allow successful removal. 1

Step 3: Endoscopic Extraction

For high-lying objects (above rectosigmoid junction) or after failed transanal attempts, use rigid or flexible sigmoidoscopy with polypectomy snare, endoscopic grasper, or net. 1

• Fluoroscopy can assist with visualization and extraction. 1

Step 4: Surgical Intervention

If transanal and endoscopic extraction fail, proceed to surgery. 1

• Use a "step-up" laparoscopic approach if skills/equipment available: laparoscopy to assess for perforation, then laparoscopic-assisted downward milking of the object for transanal extraction. 1
• Proceed to colotomy only if milking fails. 1
• Objects migrating into the sigmoid colon increase operative intervention risk 2.25-fold. 1

If Perforation Discovered:

• Small, recent perforation with healthy, well-vascularized tissue and no tension: Primary suture repair. 1
• Clinically stable patient without anastomotic leak risk factors when primary suture not feasible: Resection with primary anastomosis ± diverting stoma. 1
• Critically ill patient, extensive contamination, or high anastomotic leak risk: Hartmann's procedure. 1

Post-Extraction Management

Perform proctoscopy or flexible sigmoidoscopy after removal to evaluate bowel wall integrity, identify mucosal lacerations, detect supernumerary fragments, and rule out perforation. 1

• While some advocate clinical observation alone, significant post-extraction perforation rates support routine endoscopy. 1
• Light bulbs can fracture during extraction, leaving glass fragments that require identification. 4
• Mean hospital stay is approximately 3 days for uncomplicated cases. 4

Special Considerations

• If drug concealment suspected: Avoid any maneuver (including endoscopy) that could disrupt drug packages due to life-threatening overdose risk. 1
• Antibiotic prophylaxis: Not routinely needed unless perforation, peritonitis, or strangulation present; then administer empiric broad-spectrum antibiotics based on local resistance patterns. 1
• Psychological evaluation: Consider referral, as rectal foreign bodies may indicate underlying psychiatric issues or sexual assault requiring investigation. 1, 5