Teaching Case

A 39-year-old male patient presented to the emergency department with a 4-hour history of pain in the RLQ (right lower quadrant), nausea and vomiting. Physical examination showed RLQ tenderness, although rebound tenderness was not present. Laboratory evaluation revealed leukocytes 14.4 x 109/L, CRP 10.7 mg/L.

Plain abdominal radiography evidenced a spherical high density foreign body in the RLQ (Fig.1). Patient underwent abdominopelvic CT where the foreign body was identified as a lead shot located in the middle third of the appendix. The appendix was mildly dilated and no other signs of appendicitis were noted (Fig.2). Patient was a hunter and admitted eating wild game, this being the origin of the ingested foreign body. After analgesic treatment the patient was asymptomatic, and was discharged with follow-up, showing no recurrence of pain.
Five months after the main episode the patient presented again at the emergency department with similar symptomatology. This time the lead shot could not be identified in the plain abdominal radiography (Fig.3). Abdominopelvic CT revealed that the lead shot had been expelled from the appendix, and from the patient's body, mild dilatation of the appendix with thickening of its walls was also seen, but again no other signs of appendicitis were noted (Fig.4).

Foreign bodies are a rare cause of appendicitis. Nevertheless, this entity was more common in the past century due to eating wild game (ingested shot pellets) and the frequency of hand sewing (swallowed needles and pins due to holding them between the lips). [1]

In most cases, ingested foreign bodies pass through the alimentary tract without incidence. But if the foreign body arrests in the caecum it can gravitate to the appendiceal orifice and enter the appendiceal lumen (except in the event of a retrocaecal appendix, where there is almost no risk for an object to enter the appendiceal lumen). The clinical presentation can vary from hours to years. Sharp, thin and pointed objects are more likely to cause perforations and other complications. In return, blunt foreign bodies are more likely to remain quiescent for longer periods and may cause appendicitis through obstruction of the appendiceal lumen the same way as appendicoliths. [3] However, many documented cases show that a foreign body in the appendix even after many years may not always lead to an authentic appendicitis either histologically or clinically. [2,4]

When a foreign body is located in the RLQ and its position does not change, appendiceal location must be suspected. Once in the appendix, it is postulated that peristaltic action is insufficient to expel foreign bodies back into the caecum and colonoscopic removal is indicated. If this is unsuccessful, laparoscopic-guided removal may be performed to prevent further complications. [4]

Our case clearly illustrates a blunt foreign body located in the appendix which is later expulsed from the patient's body, a rare circumstance that as far as we know has not been reported before.