Duodenal perforation nine months after accidental foreign body ingestion, a case report
Foreign body ingestion is a scenario occasionally encountered in the emergency room. Pediatric and psychiatric patients are the two most common populations suffering from accidental or in some cases intentional ingestion of foreign bodies. Commonly, majority of cases require no specific treatment and the swallowed objects pass through the digestive tract spontaneously without causing any significant complications. Less than 1% of the cases complicates with gastrointestinal tract perforation, which are often caused by sharp objects, which warrants surgical intervention. The average time from foreign body ingestion to development of perforation was noted at 10.4 days in previous reports. These cases often present in rapidly progressing peritonitis and are subsequently managed by emergent laparotomy. In this case report, we describe an accidental chopstick ingestion of a patient who initially was misdiagnosed and remained asymptomatic for nine months, then presented with acute abdomen.
A 27-year-old man accidentally ingested a wooden chopstick and sought consult at a clinic. Negative abdominal plain film misled the physician to believe ingested chopstick was digested into fragments and passed out unnoticed. The patient presented acute abdomen caused by duodenal perforation nine months later and was subsequently treated with emergency laparotomy with primary duodenorrhaphy.
Negative plain films are not sufficient to conclude a conservative treatment in foreign body ingestion. Computed tomography scan or endoscopic examinations should be done to rule out retained foreign body within gastrointestinal tract.
KeywordsForeign body Duodenum Perforation
Right upper quadrant
Ingestion of foreign bodies may be encountered from time to time in clinical practice. Small objects like coins, buttons or toy compartments are frequently accidentally swallowed by children whereas particular objects are associated with intentional ingestion by psychiatric patients. In prior studies, around 1% of foreign body ingestion complicates with significant clinical sequela like gastrointestinal (GI) tract obstruction or hollow organ perforation [1, 2]. These conditions are often caused by large or sharp objects with subsequent development of unpleasant symptoms shortly after the accidental ingestion which will prompt patients to seek medical consult.
To the best of our knowledge, few reports have described upper GI tract perforation associated with foreign body ingestion which developed more than half year from the time of ingestion to onset of symptoms . We intend to present a case of an accidental ingestion of a chopstick (11 cm in length), of which the perforation of duodenum occurred nine months after the accidental ingestion.
Timeline of history, intervention and outcomes
History and treatment course
Local clinic visit
Abdominal plain film: negative
April 17, 2018
RUQ abdominal pain
Local clinic visit
Persisted abdominal pain
April 19, 2018
RUQ abdominal pain with radiation to back
Outpatient clinic visit
Abdominal CT: foreign body penetration over duodenum
April 20, 2018
RUQ abdominal pain with radiation to back
Remove foreign body
April 26, 2018
Complete resolution of abdominal pain
On soft diet
April 28, 2018
The patient had stable vital signs at our outpatient clinic. He denied any chronic illness or surgical history. He denied psychological disorder as well, and drank only in social occasions. The patient however volunteered the history of the accidental ingestion of a wooden chopstick nine months prior to which he sought consult a few days after that incident. The attending physician requested for an abdominal plain film which turned out to be unremarkable and offered the explanation to the patient that the chopstick may have been digested into fragments and will pass out unnoticed. After that consult, patient remained asymptomatic for nine months.
The patient recovered well after surgery. Sips of water were started on the 2nd post-operative day and soft diet on the 6th post-operative day. There were no note of febrile episode or recurrence of abdominal or back pain after surgery. Patient was discharged stable on the 8th post-operative day.
Discussion and conclusions
Foreign body ingestion in adults are often related to mental retardation, alcohol drinking, or psychiatric disorder [4, 5]. The case mentioned in this report was mentally normal, although at the time of the accidental ingestion, the patient was alcohol intoxicated. In previous reports, small objects generally pass through GI tract without complications, while large, sharp, or caustic ingested foreign bodies will usually cause an unpleasant symptom or severe complications like GI tract perforation shortly after ingestion [1, 2, 6]. The average time from ingestion of foreign body to occurrence of perforation was 10.4 days . Only one case report from China presented foreign body embedded in esophageal mucosa for ten months before endoscopic removal .
Our case was aware of the ingestion of chopstick. The negative clinical symptoms/signs and unremarkable plain film on initial consult misled the initial attending physician, which resulted in delay of proper management. The swallowed chopstick remained intact in his upper GI tract for nine months (from July 2017 to April 2018) before causing significant complication. Such history should alert clinical practitioners that lack of symptoms and negative plain films are not sufficient to conclude a conservative treatment in foreign body ingestions. Computed tomography scan or endoscopic examinations should be done to rule out retained foreign body within GI tract.
Clinical presentation of our case after duodenal perforation was compatible with the statistic results in previous studies [4, 7, 8]. He remained afebrile throughout the entire course, and did not present typical signs of acute abdomen. Instead, his back pain was the chief complaint at the time of consult. Detailed history taking is crucial since patients may not be aware of foreign body ingestion in some cases. The possibility of hollow organ perforation should also be excluded before endoscopic examinations.
CL and DE were major contributors in writing the manuscript. CY was the attending physician and operator of this patient and is the leader of the medical team. All authors read and approved the final manuscript.
There is no funding of this study.
Ethics approval and consent to participate
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The ethics committee at Kaohsiung Chang Gung Memorial Hospital has approved the case report to be submitted.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
- 6.Gambardella1C, Allaria1A, Siciliano1 G, Mauriello1 C, Patrone1 R, Avenia N, et al. Recurrent esophageal stricture from previous caustic ingestion treated with 40-year self-dilation: case report and review of literature. BMC Gastroenterol. 2018;18(1):68–72.Google Scholar
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