Clinical History
A young male patient presented to the outpatient department for abdominal discomfort. On clinical examination, a hard lump feeling like a neoplastic lesion was noted in the right flank. A few hours after admission the patient suddenly developed severe abdominal pain. Guarding was present, so the patient was referred for radiological investigations.
Imaging Findings
The patient was taken for non-contrast computed tomography to rule out acute abdominal conditions like perforation/obstruction as per local protocol.
NCCT abdomen revealed free intraperitoneal air and peritoneal collection. An abnormal structure was noted adjacent to the ascending colon in the peritoneal cavity. That structure was mimicking bowel and was filled with fluid density material. The wall of this abnormal structure mimiced air in the bowel wall. This picture created confusion for the final diagnosis. After multi-planar reconstruction this structure was confirmed to be a foreign body in the peritoneal cavity in right lumbar region in subhepatic location shaped like a bottle.
Discussion
In most of the cases the clinical history of foreign body ingestion or insertion is rarely available and in such cases the clinical suspicion is generally low due to nonspecific manifestation. Therefore, CT analysis is important for establishing the diagnosis. The identification of a foreign body in the gastrointestinal tract is essential for the diagnosis of foreign body [1]. Extraluminal findings of localized pneumoperitoneum and fat stranding adjacent to a thickened bowel loop in the presence of foreign body suggests the possibility of a foreign body causing perforation [2].
In our case we did not get a significant clinical history. During analysis of non-contrast computed tomography images, we found an abnormal structure in right subhepatic region in the peritoneal cavity adjacent to the ascending colon. Also few associated findings like extraluminal free air and peritoneal collection was noted. Provisionally as per above findings, we suspected a foreign body causing bowel perforation. Three-dimensional reconstruction and minimal streak artefact helps us to conclude that a bottle-shaped nonmetallic foreign body measuring 14x3.7 cm was present in the peritoneal cavity. Within a few hour the patient’s condition deteriorated, so immediate surgical exploration was done. This revealed a large plastic bottle in the peritoneal cavity which was filled with fecal matter. A large perforation was detected at the junction of the distal descending colon and rectum. The foreign body was removed and the perforation site was closed surgically. We thought that the bottle was inserted perrectally some time ago which led to colonic perforation later. The possibility of bodypacker could not be rule out as there can be a possibility of expulsion of packed content over a time and replacement by fecal matter [3]. However, the possibility of bodypacker was low in the current circumstances.
Recognition of a foreign object is crucial for prompt medical management. In our case CT allowed an accurate diagnosis of the nature and location of the foreign body and its associated complications.
Differential Diagnosis List
A plastic bottle foreign body causing colonic perforation
Bodypacker
Perforation peritonitis
Final Diagnosis
A plastic bottle foreign body causing colonic perforation
