Case Report Foreign bodies in the rectum: A report on three cases including a bullhorn in the rectum Shilpi Singh Gupta a, * , Onkar Singh a , Ankur Hastir b , Sumit Shukla a , Raj Kumar Mathur a a Department of Surgery, MGM Medical College & MY Hospital, Indore 452 001, India b Department of Surgery, MGM Medical College & Hospital, Kamothe, Navi Mumbai 410 209, India article info Article history: Received 2 January 2010 Accepted 29 March 2010 Keywords: Foreign bodies Rectum abstract Foreign bodies in the rectum (FBR) are not rare. In the majority of cases these are self inserted by children and young adults as a result of sexual gratification, in psychiatric patients or inserted forcibly in victims of assault. Due of vague history, varied symptomatology and the variety of objects including different sizes and shapes, these often pose management problems. Management depends on the characteristics of the object and on the presence of peritonitis or pelvic abscess. Approach to management should be stepwise. Only three cases of cattle horn in rectum have been described so far; we report herewith on a fourth one. We describe three patients with different FBR treated in our institution along with review of the relevant literature. Ó 2010 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved. Introduction Although the exact frequency of this practice is not known, but definitely, forcible or self insertion of foreign bodies into the rectum (FBR) is not uncommon. FBR frequently present manage- ment difficulties to the surgeons. Most patients with FBR present either after failed efforts to remove the object at home or when it has caused perforation. Patients frequently give vague history. Delayed and varied presentation, along with numerous objects of different sizes and shapes finding their way into ones rectum, fur- ther complicate the situation. Thus we intended to present a review of the literature along with an analysis three of our own cases. Case reports Case 1 A 36-year-old married man presented a day after self insertion of a glass bottle into his rectum. He was unable to remove it at home. He used to insert a polished wooden handle of a toilet clean- ing brush through his anus, but this was his first time with glass bottle. A plain upright abdominal radiograph (Fig. 1A) showed the bottle (with its mouth upright) near the rectosigmoid region, and no free gas. On rectal digital examination the lower end of the bottle could be felt 7 cm above the anal verge. There were no signs of perforation. The bottle was successfully extracted by bimanual manipulation after full sphincter relaxation under spinal anaesthesia (Fig. 1B). The patient was referred for psychological counseling but he refused it. Case 2 A 28-year-old married male presented at the emergency department with complains of difficulty in passing faeces. On abdominal examination, a cone shaped structure was felt in the lower central abdomen and there were no signs of perforation. On rectal examination his anal opening was patulous, and the lower end of a foreign object was just palpable as sharp projections with hollow interior. A pelvic radiograph did not show the exact object, but only a conical impression of the faecal matter and gas (Fig. 2). The patient gave history of bullhorn injury around 25 days back while he was feeding a bull and it suddenly got violent and attacked him. According to the patient the horn of the bull entered his anus got broken and impacted in the rectum. A CT-scan of the abdomen and pelvis showed the bullhorn with sharp edged open base facing downwards, located just near the rectosigmoid junc- tion (Fig. 3A and B). Suspicion of a small left anterolateral tear in the lower rectum was raised on CT. There was no obvious free gas or fluid within the peritoneal cavity. The patient was taken for left lower exploratory laparotomy, as attempts to remove the horn through the anus even under spinal anaesthesia were not suc- cessful. A 12 cm long broken horn with sharp projecting edges, which was painted blue, was removed through a sigmoid colos- tomy (Fig. 4A–C). In view of suspicious rectal tear, a de-functioning sigmoid colostomy was done. On further careful questioning the patient admitted regular self insertion of bullhorn but this was 1687-1979/$ - see front matter Ó 2010 Arab Journal of Gastroenterology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ajg.2010.03.002 * Corresponding author. Address: VPO-Sangowal, Tehsil-Nakodar, District- Jalandhar, Punjab 144 041, India. Tel.: +91 98937 77321. E-mail address: drguptashilpi@gmail.com (S.S. Gupta). Arab Journal of Gastroenterology 11 (2010) 108–112 Contents lists available at ScienceDirect Arab Journal of Gastroenterology journal homepage: www.elsevier.com/locate/ajg