Teaching Case

A 74 years old female presented with symptoms and signs compatible with acute abdomen. The abdominal pain initiated before two days with loss of appetite and vomits.

A 74 years old female with a free history evaluated for acute abdomen. The abdominal pain was generalized. On clinical examination of the abdomen there was abdominal tenderness and generalized abdominal pain combatable with acute abdomen. The abdominal pain initiated before two days with loss of appetite and vomits. The patient underwent ultrasound and computed tomography examination. The ultrasound examination was normal and CT scan revealed an organized infiltration of the mesenteric fat at the mesenteric root. (Figure 1) next to it a hyperdense object was visualized (Figure 2). At multiplanar imaging reconstruction the object projected on the duodenal wall one half and the other half projected at the area of the organized mesenteric infiltration. Laparatomy performed and the object was a sharp lamb bone.  

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, and 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.