Author(s)

Voultsinou D., Kehalaki Syrgani E., Voultsinos V., Adoniou A.,Palladas  

Patient

male, 71 year(s)

A 71 years old male presented with symptoms and signs compatible with acute abdomen. The abdominal pain initiated before two days.

A 72 years old male with history of operated stomach cancer evaluated for acute abdomen. The abdominal pain was generalized, when he asked he indicated the left lower abdomen as an initiating point two days ago. On clinical examination of the abdomen there was abdominal tenderness and generalized abdominal pain compatible with acute abdomen. The patient underwent ultrasound and computed tomography examination. The ultrasound examination was normal and CT scan revealed free intraperitoneal fluid and air (Figure 1). At the level of the sigmoid colon a hyperdence structure with inner lucency was observed with imaging finding characteristic of bone (as a chicken bone Figure 2). At the supine position the object was still entrapped at the sigmoid colon wall (Figure 2b). At multiplanar reconstruction scan (Figure 3), the foreign body projected on the sigmoid lumen one part and the other part projected on wall giving the impression of laceration and infiltration of pericolic fat. An abdominal plain film retrospectively examined, demonstrates a linear hyperdence structure at the level of sigmoid colon. (Figure 4).   Laparatomy performed and the object was a chicken bone(Figure 5).

Foreign bodies may be ingested, inserted into a body cavity, or deposited into the body by a traumatic or iatrogenic injury. Most ingested foreign bodies pass through the gastrointestinal tract without a problem. However, ingested or inserted foreign bodies may cause bowel obstruction or perforation; lead to severe hemorrhage, abscess formation, or septicemia; or undergo distant embolization. Metallic objects, except aluminum, are opaque, Most animal bones and all glass foreign bodies are opaque on radiographs. Most plastic and wooden foreign bodies (cactus thorns, splinters) and most fish bones are not opaque on radiographs. Foreign body ingestions or insertions are seen in three broad categories of patients: children, psychiatric patients and prisoners and elderly (especially those who have decreased cognitive function, impaired swallowing after a stroke, or poorly fitting dentures). Children account for about 80% of foreign body ingestions. Τhe incidence is slightly higher in men than in women. The vast majority of all swallowed objects pass through the gastrointestinal tract without a problem Elongated or sharp objects, are more likely to lodge at areas of narrowing (bowel adhesions or strictures) or to impinge at regions of anatomic acute angulation(^.duodenal loop, duodenojejunal junction, appendix, and ileocecal valve region). Less than 1% of ingested foreign bodies cause perforation of the gastrointestinal tract. Sharp, elongated objects are the most likely to penetrate the bowel or esophageal mucosal lining and cause significant injury to the bowel wall or frank perforation. Perforations are more common in the ileocecal region or the appendix. Metallic objects such as needles or elongated objects such as fish bones, chicken bones, and toothpicks are the foreign bodies most frequently reported to have caused a perforation. In many cases, these types of perforations do not occur acutely or cause acute symptoms. The object may only partially perforate the bowel wall and produce a chronic inflammatory process that has few symptoms, being discovered months or years later. Sometimes, these chronic inflammatory processes are discovered when they produce unusual areas of opacity or lucency on radiographs obtained for other reasons. Sometimes, they are discovered at abdominal surgery performed for another reason. Even at surgery, the foreign body may be hard to diagnose because of its encrustation by bile and mineral salts. Plain radiographs typically have been used in patients who have swallowed bones, although the yield is low, with only 20-50% of endoscopically proven bones visible on plain radiographs. If the object has moved farther down in the gastrointestinal tract or removal is not successful, the patient should be followed with daily abdominal x-rays until the object is expelled. Barium swallow can be used for food impactions; however, most authorities believe that it adds nothing to the evaluation and delays definitive treatment. .CT scanning is also the imaging modality of choice in cases of suspected perforation or abscess. Patients in whom endoscopic retrieval of foreign bodies failed are often referred for surgical extraction, but there are no good data to support this invasive policy.