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Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2418895510.5144/0256-4947.2013.514asm-5-514ImagesRectal perforation due to a lost toothbrush Rashid Arshad aKhuroo Suhail bNazir Saima c
a Department of Surgery, Government Medical College, Srinagar, India
b Department of Surgery, Northern Railway Central Hospital, Delhi, India
c Department of Pathology, Government Medical College Srinagar, Srinagar, IndiaCorrespondence: Dr. Arshad Rashid, Department of Surgery, Government Medical College, Srinagar, Karan Nagar Srinagar 190010, India, T: +917838194782; F: +918059931539, arsh002@gmail.comSep-Oct 2013 33 5 514 515 Copyright © 2013, Annals of Saudi Medicine2013This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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Inserted rectal foreign bodies are generally seen in mentally challenged or sexually deviated persons and often pose a challenging diagnostic and therapeutic dilemma.1 Retained rectal foreign bodies may present with perforation, obstruction, or bleeding.1

A 54-year mentally challenged female presented to the surgical emergency with the features of subacute intestinal obstruction with a lump palpable in the left iliac fossa and normal rectal examination. All attempts to manage the patient conservatively ultimately ended in futility. A contrast-enhanced computed tomography abdomen was ordered, and, to our surprise, it revealed the presence of a tooth brush within the rectum with free air pockets and distended gut loops around it (Figure 1). The patient underwent an emergent exploratory laparotomy. Exploration revealed matted gut loops and omentum in the left iliac fossa with minimal fecal contamination of the peritoneal cavity. After the adherent gut loops were separated, the tooth brush came into view. The tooth brush had perforated the rectal wall, and a part of it was lying outside the rectum (Figure 2). The tooth brush was retrieved, and as the surrounding rectal wall was not healthy, a Hartmann procedure was done.

Although rectal foreign bodies have been reported in all ages and ethnicities, they are most commonly seen in men in the age group of 30 to 50 years. A variety of objects have been described in the published reports, and the list includes vibrators, dildos, cucumbers, apples, light bulbs, knives, nails, bottles, utensils, drug packets, and so on.1 Although a toothbrush present as a foreign body in the rectum has been previously reported,2 but such a presentation as has been reported in this study is the first of its kind.

An important problem encountered in the management of rectal foreign bodies is the delay in presentation, as many patients may be embarrassed and conceal the history. As our patient was mentally challenged, we were not able to extract the proper history from her, but she vaguely remembered inserting the toothbrush rectally.

Retained rectal foreign bodies can be managed by colonoscopic extraction, but in the setting of perforation, surgical intervention is mandatory.1

Consent

As the patient was mentally challenged, a written and informed consent was taken from the brother of the patient for this publication. The brother gave the consent on the condition of maintaining the anonymity of the patient. We have kept our promise and have not revealed the identity of the patient in any manner.

Figure 1 Reconstructed contrast-enhanced computed tomography image showing the presence of toothbrush with pneumoperitoneum within the abdomen.

Figure 2 Toothbrush seen coming out of a mass of matted gut loops.
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REFERENCES
1 Goldberg JE  Steele SR   Rectal foreign bodies Surg Clin N Am 2010 90 173 184 20109641 
2 Kumar M   Don’t forget your toothbrush! Br Dent J 2001 191 1 27 28 11491473