Rectal foreign body of suppository package: risk of self‐insertion of suppositories among elderly

Although drug packages are known to be a risk for upper gastrointestinal injury by accidental ingestion, they are not a common cause of rectal foreign bodies. Recently, we experienced a potential first case of a rectal foreign body caused by trans-anally inserted suppository packaging. A 78-year-old woman, diagnosed with Parkinson’s disease 6 years ago, was administered droxidopa and pyridostigmine for orthostatic hypotension over the course of a month. However, she developed diarrhoea and had to be admitted to adjust her dosage. The pyridostigmine dosage reduction improved the diarrhoea, but she developed constipation thereafter. Therefore, we decided to use a sodium bicarbonate and anhydrous sodium dihydrogen phosphate suppository. The patient insisted on self-insertion, due to which the nurse peeled off half the package and gave it to her. Immediately afterward, the patient complained of pain in the anal region and when we interviewed her, we found that she had inserted the suppository with the packaging still intact. The package could be felt upon rectal examination, but it was difficult to remove manually. Hence, the surgeon was consulted and it was removed through bedside anoscope (Fig. 1). No rectal ulcer or perforation occurred and, as planned, the patient was discharged two days later. Rectal foreign bodies are potentially dangerous due to a risk of gastrointestinal perforation and require prompt removal. Most are intentionally inserted via the anus during sexual activity, but sometimes they can be any of the following: accidental ingestion of toothpicks, meat or fish bones, or drug packages that get caught around the rectoanal transition. However, there are no reported cases of rectal foreign bodies developed after accidental insertion of suppository packages via the anus. Accidentally ingested suppository packages, as well as other drug packages, are a reported rectal perforation risk. If the packages are inserted in open position from the anus, they are difficult to remove because the flipped part of the package gets stuck like a fishhook. Since suppository packages are small and not visible on x-rays, elderly patients might be unable to reveal the history of insertion and consequently, delayed detection can lead to rectal ulceration or perforation. Therefore, we need to be aware of the potential risks of self-insertion of suppositories among the elderly, especially those who are cognitively