Accidental ingestion of foreign bodies is a common condition in clinical practice. However, small bowel perforation due to ingestion of foreign bodies has been rarely seen. In this article, we report a case of small bowel perforation due to ingestion of foreign body. A 38-year-old female patient, presenting with complaints of acute abdomen for 2 days, was admitted to the emergency department. She denied nausea and vomiting. The patient had tenderness and positive rebound tenderness in the right lower quadrant. Contrast-enhanced abdominal computed tomography has been performed. This revealed distended ascending colon and oral contrast retention denoting delayed bowel emptying. The patient was operated for. A micro perforation due to fish bone was detected in the jejunum. The patient underwent debridement and primary repair. The patient was discharged postoperative 6th day without problem. Bowel perforation due to the ingestion of foreign bodies should be considered in the differential diagnosis of acute abdomen.

Acute abdominal pain is a very common complaint that can be seen in emergency room, reasons vary from simple to serious. One of the rare and serious reasons for developing acute abdominal pain is foreign body swallowing.

Still, most of swallowed foreign bodies can be passed with stool without any serious complication or damage and need only observation. Some other serious complications may happen and lead to bowel obstruction or fistula and can be life-threatening.

Only one percentage of these cases can cause bowel perforation, usually this happens at ileum level [1, 2]. Radiology study plays an important role to diagnose the swallowed foreign bodies a complication related to it; the golden standard study is the computerized tomography (CT), especially in preoperative time.

We should consider intestine perforation in patient with acute abdomen signs with a history of swallowed foreign bodies, early diagnosis, and intervention is important in such patients [3‒6]. This study will discuss a case of foreign body swallowing led to small intestine perforation and the process of diagnosis and surgical treatment.

A 38-year-old patient female, came to emergency room with a complain of diffuse abdominal pain for the last 2 days, CT study 2 days before suspected acute appendicitis, study done in another city. The patient was cooperative, and on examination, there was tenderness in both iliac fossa, positive rebound tenderness in right iliac fossa, no rigidity and bowel sound were reduced.

Laboratory Investigations Showed:

  • white blood cells 6.8/normal low 3.4, normal high 10.8/(normal: 41–73)

  • neutrophil automated percentage 60% (normal: 5.2–12.4)

  • C-reactive protein 31.05 mg/L (normal: 0–10)

  • urine test and other blood investigations were normal.

Abdomen Ultrasonography (US) Result:

  • minimal free fluid, no ultrasound criteria of appendicitis.

CT abdomen and pelvic showed distended ascending colon, no definite criteria of appendicitis, right adnexal fullness with surrounding free fluid in pelvic (Fig. 1). Considering these findings, patient was admitted for observation and planning for surgery with clinical correlation, considering continuous pain.

Fig. 1.

CT findings distended ascending colon.

Fig. 1.

CT findings distended ascending colon.

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The patient was shifted to operation room with a plan of diagnostic laparoscopy and procedure depends on the intraoperative findings. Pneumoperitoneum created by Veress needle and three trocars of 5 mm have been introduced under direct vision, diagnostic phase revealed normal appendix and unremarkable major organs, minimal free fluid found in pelvic, checking small bowel revealed thick mid-jejunum loop attached to peritoneum, by examination small perforation found due to foreign body (fishbone) (Fig. 2).

Fig. 2.

Mid-jejunum perforation due to fish bone.

Fig. 2.

Mid-jejunum perforation due to fish bone.

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The foreign body was removed; a perforation area was located and confirmed on the inflamed and oedematous jejunum. Minimal serous free fluid was found, the perforation site was debrided and primary repaired with two interrupted stitches 3/0 PDS extra mucosal.

Later during the follow-up and observation period, the patient informed us that she had a fish meal 3 days before symptoms started. Parenteral antibiotics were given postoperatively with smooth recovery and patient was discharged in stable condition within 6 days.

However, swallowing foreign bodies is common, rare cases can cause serious complications. Only one percentage of these cases can cause intestinal perforation which is usually at the ileum level [1, 2].

Mostly the foreign bodies causing gut perforation are pointed materials like toothpicks, chicken, or fishbones [7]. Other materials like batteries, nail clippers, pens, and nails may also cause gut perforation [8]. Also there are some cases were documented with intestinal perforation due to biliary stent migration [9].

The most common cause of bowel perforation vary from study to another; it could be chicken bones like in study of Madrona et al. [2]; fishbones according to report of Chu et al. in Hong Kong [10] and another of Goh et al. [4]. Usually, the perforation site associated with swallowed pointed foreign bodies is the angulated bowel segment as rectosigmoid or ileocecal junctions, still it may happen in any site along the gastro intestinal tract [11].

The most common site of perforation found to be terminal ileum (38.6%) according to Goh et al. study [12] and the distal ileum due to its narrow lumen according to Coulier et al. [3]. Other rare sites as appendix, hernia sac, and Meckel diverticulum were documented [13].

In the case, we are presenting the perforation was found 15 cm proximal to ileocecal junction. Different symptoms and signs can present the bowel perforation due to foreign bodies swallowing; in our case, the acute abdominal pain was the presenting symptom.

In another literature, different signs and symptoms were documented such as inflammatory masses, omental pseudotumor, localized abdominal abscess, intra-abdominal bleeding, renal or ureteral colic, bowel obstruction, and Colo vesical or enter vesical fistula [3, 5, 13]. Even Asymptomatic presentation was documented [14].

There are some risk factors increasing the chance of accidental swallowing of foreign bodies such as advanced age (as in our case), loss of touching sensation with dental prosthesis, food preparation, and rushed eating habits [3]. There are different radiology studies can provide diagnosis of bowel obstruction due to foreign body.

Diagnostic signs differ from one radiology modality of diagnosis to another. An abdominal X-ray can detect metal foreign bodies, intra peritoneal free air associated with bowel perforation or obstruction. An ultrasound study can detect the free fluid intra-abdomen and may help to exclude other possible diagnosis.

The advantage of CT that it can detect bowel perforation due to non-metallic foreign bodies like fishbone. Not radio-opaque foreign bodies can be detected by US due to background shadows and high reflectivity [15]. We still considered that CT is the first method of choice to detect foreign bodies and to evaluate acute abdominal pain patients [3]. It is due to the high resolution and the full detailed information about all GIS we can get by CT.

Although we can see changes in the surrounding tissues of the perforation area by US, but some other factors can limit the US function such as perforation site and observer experience. So the treatment of Bowel perforation due to foreign bodies is surgical before developing any further complications.

Treatment plan for possible complications like fistula or abscess would be observation, radiological intervention, surgical repair, or segmental resection [12]. In the case, we are presenting perforation was micro bowel perforation so surgical debridement and primary repair was performed.

As always getting a full proper history from the patient, choosing the appropriate radiology study will lead physicians to the correct diagnosis. And it is important to consider bowel perforation due to foreign bodies ingestion among the differential diagnosis of patients with acute abdomen complaint.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The case report was sent to the hospital Ethics Committee and they approved for publication.

REC study number KCH-REC-013, on August 15, 2022. King’s college hospital Ethics Committee.

The authors have no conflicts of interest to declare.

Authors confirmed not receiving any financial support

Mouhsen AL Hosein collects the data and writes the initial manuscript; Ali Eghtedari revises the manuscript and approve for publication; both authors participated in the same surgery.

All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author. Small intestine perforation due to foreign body, case report

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