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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 2  |  Issue : 3  |  Page : 103-106

Gastrointestinal complications of multiple foreign body ingestion with malrotation of the gut


1 Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Bandra; Department of Pediatric Surgery, Bai Jerbai Wadia Children's Hospital, Parel, Mumbai, Maharashtra, India
2 Department of Pediatric Surgery, Bai Jerbai Wadia Children's Hospital, Parel, Mumbai, Maharashtra, India
3 Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Bandra, Mumbai, Maharashtra, India

Date of Web Publication15-Dec-2014

Correspondence Address:
Rajeev Redkar
14, Buildarch Terrace, 1st Floor, Sitladevi Temple Road, Mahim, Mumbai 400 016, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.147034

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  Abstract 

Foreign body (FB) ingestion is a common problem in the pediatric age group, and most pass spontaneously through the gastrointestinal tract. But the presence of anatomical variants like malrotation of the gut may lead to complications. Our patient, a 5-year-old male presented with pain in the abdomen and radiological imaging diagnosed a metallic FB in the small bowel with ileo-ileal intussusception. Exploratory laparotomy with removal of FBs (metallic ring and cotton fiber bezoar), intussusception reduction followed by closure of perforations was done. The patient had an uneventful recovery. This case is perhaps the first instance of small bowel perforations and intussusception following FB ingestion in a child with malrotation of the gut.

Keywords: Foreign body, intussusception, malrotation, perforation


How to cite this article:
Redkar R, Karkera PJ, Ramachandra M, D'Souza F, Krishnan J, Hathiramani V. Gastrointestinal complications of multiple foreign body ingestion with malrotation of the gut . Saudi Surg J 2014;2:103-6

How to cite this URL:
Redkar R, Karkera PJ, Ramachandra M, D'Souza F, Krishnan J, Hathiramani V. Gastrointestinal complications of multiple foreign body ingestion with malrotation of the gut . Saudi Surg J [serial online] 2014 [cited 2021 May 14];2:103-6. Available from: https://www.saudisurgj.org/text.asp?2014/2/3/103/147034


  Introduction Top


Foreign body (FB) ingestion is a common event, usually seen in children, alcoholics, mentally handicapped and edentulous people wearing dentures. [1] The type of FB and incidence differs by the geographical location with toys and fish bones ingestion being common in Asia while coin ingestion being common in America and Europe. [2] The gastrointestinal (GI) tract is quite resistant to perforation and most of the FBs pass through the GI tract without any complications and requirement of any intervention-surgical or endoscopic. Failure of passage of an FB should raise the suspicion of a complication or an anatomical variant. [3] Any FB having an extended stay in the GI tract may lead to obstruction, perforation or hemorrhage. GI perforations caused by ingested FBs are seen in < 1% of the cases, mostly by sharp objects. [1],[4]

We present an interesting case of ingestion of multiple FBs leading to duodenal perforations and ileo-ileal intussusception in 5-year-old boy with malrotation of gut and briefly review the complications of FB ingestion and its management .


  Case Report Top


A 5-year-old male child was referred to our institution as a case of acute pancreatitis with an abdominal ultrasound suggestive of the bulky pancreas. He presented with the complaints of abdominal pain, colicky in nature, more in the umbilical and right lumbar region since 2 days. There was no history of fever, vomiting or altered bowel habits. Clinical examination, at the time of admission, revealed tenderness in the right upper quadrant and umbilical region, but no guarding, rigidity or signs of peritonitis. Hematological investigations revealed an elevated total leucocyte count (19,200/mm 3 ) and serum lipase (584 U/L). Serum amylase and rest of the blood investigations were normal.

With a provisional diagnosis of acute pancreatitis in mind, to confirm the diagnosis an abdominal ultrasound was ordered in our institution. It revealed normal pancreas, but there was the presence of a long segment intussusception extending from the right iliac fossa to the right hypochondrium involving small bowel loops [Figure 1]. A ring-shaped metallic FB was also noted in the right lumbar region in a small bowel loop, most likely intraluminal. Polysplenia was also noted. In view of these findings and to decide, the necessity of surgical intervention, a contrast (oral and intravenous) enhanced computerized tomography (CT) scan of the abdomen was done. CT abdomen confirmed the presence of ileo-ileal intussusception. In addition, it showed that the metallic FB present in a small bowel loop was partially extraluminal, suggestive of bowel perforation [Figure 2]a. In addition, failure of the duodenum to cross the left side, along with small bowel loops on the right side and colon on the left side of the abdomen was noted, which was suggestive of partial malrotation [Figure 2]b. In view of the clinical and radiological findings, the decision to do an emergency exploratory laparotomy was taken.
Figure 1: Ultrasound abdomen showing ileo-ileal intussusception in right hypochondrium

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Figure 2: Computerized tomography abdomen (a) Metallic foreign body involving small bowel loops in right lumbar region, (b) Small bowel loops predominantly on the right side and large bowel loops on the left side

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Figure 3: (a)Intra-operative picture-metallic ring and the duodenal perforations (arrow and artery forceps point to the perforations) (b) Extracted foreign bodies-metallic ring and cotton fiber bezoar

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On exploration, caecum was found in the left hypochondrium with the presence of Ladd's bands. There were two perforations in the second part of the duodenum caused by the metallic ring [Figure 3]a. There were multiple ileo-ileal intussusceptions, with an intraluminal soft FB as a lead point for the distal most intussusception.

The Ladd's bands were divided; the metallic ring was removed, intussusceptions reduced manually. The soft FB in the ileum was milked back into the duodenum and removed. It was a mass of large cotton threads [Figure 3]b. Duodenal perforations were closed. Postoperative course was uneventful. Orals were allowed on postoperative day 8, after an upper GI contrast series [Figure 4], which showed no contrast leak and small bowel loops interspersed all over the abdomen. After recovery, the child was referred to the child psychologist to treat his unusual eating habits.
Figure 4: Postoperative contrast meal follow-through -no leak and corrected malrotation

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  Discussion Top


Most cases of FB ingestion occur in children, with a peak incidence between the ages of 6 months and 6 years. Majority of the FBs, including sharp objects, once past the esophagus, pass the rest of the GI tract uneventfully. [5],[6] However, ingestion of sharp and pointed objects, animal or fish bones, dentures, tooth picks, bread bag clips, magnets, and medication blister packs increase the risk of perforation. [5]

Perforation, impaction or obstruction of FBs are often seen at GI angulations or narrowing, hence previous GI tract surgery or congenital gut malformations increase its risk. [5],[7] Common sites for FB arrest include the upper esophageal sphincter, mid esophagus (crossover of aorta), lower esophageal sphincter, pylorus, ligament of Treitz, ileocecal valve, caecum, sigmoid colon, and rectum. [8] In our patient, the natural angulations of the duodenum and the congenital rotational anomaly of the gut probably resulted in the metallic rings arresting in the duodenum and eventually causing a perforation.

Preoperative history of FB ingestion may not be elicited in a significant proportion of the cases. [4] Mentally sound adults and older children may recollect the history of ingestion and localize the site of discomfort. However, the site of discomfort may not correlate with the site of impaction. Often, symptoms occur well after the ingestion of the FB. [9],[10]

Small bowel perforations are usually not diagnosed preoperatively because clinical symptoms are usually nonspecific and ape other surgical conditions, such as appendicitis and the cecal diverticulitis. [11] Fever, abdominal pain and tenderness may develop in case of gastric or intestinal perforation. Intestinal obstruction due to an FB may cause abdominal distension, pain, and tenderness, vomiting, fever, hematochezia, or melena. [5]

Our patient was a 5-year-old male child referred with a provisional diagnosis of acute pancreatitis, with no history of FB ingestion (the child denied FB ingestion in spite of repeated interrogation postoperatively). Only on radiological imaging was the FB with GI perforation detected. In addition, a small bowel intussusception detected on imaging, was intra-operatively diagnosed to have been caused by a bezoar of cotton fibers. FB bezoars especially trichobezoars are known to cause multiple intussusceptions although cotton fiber bezoars as a cause of intussusception is uncommon. [12]

Conservative management is sufficient in most patients as, up to 90% of FBs pass out of the GI tract spontaneously. However, early surgical intervention is recommended to reduce morbidity, at the first sign of bowel obstruction or worsening abdominal pain. [13]

Plain radiographs usually confirm the location, size, shape, and number of ingested FBs, however, fish or chicken bones, wood, plastic, glass, and thin metal objects which are radiolucent are not readily seen. [5] CT scanning and Ultrasonography can recognize radiolucent FBs. An ultrasound scan can directly visualize FBs and abscesses due to perforation. [14],[15] Contrast studies with gastrografin may be required to locate the site of impaction of the FB and identify the presence and level of perforation. Although, imaging findings may be nonspecific in some, the identification of a FB with an associated mass or extraluminal collection of gas in patients with clinical signs of peritonitis, mechanical obstruction or pneumoperitoneum strongly suggests the diagnosis. Finally, endoscopic examination, especially in the upper GI tract, can be useful in diagnosis and management of ingested FBs. [1]

Endoscopic removal of sharp objects is recommended before they have passed beyond the duodenal curve because of a greater likelihood of complications or requirement of surgical removal. If endoscopic retrieval of sharp objects is not possible, it should be followed up with daily radiographs. If there is no progress of the object in 3 days, surgical removal should be considered. Ingested blunt, radiopaque objects should be followed up with weekly radiographs and passage of an object in stool should be looked for. Surgical removal is recommended if blunt objects beyond the stomach remain in the same location for more than 1 week. [13]

Exploratory laparotomy is performed when a diagnosis of peritonitis is made following FB ingestion. [1],[16] However, laparoscopically assisted, or complete laparoscopic approaches have been reported. [11],[16] Surgical treatment may be either simple suturing of the defect or resection of the affected bowel segment followed by anastomosis. [1]

As seen in previous reports [3],[16] and our case, presence of rotational anomalies may be an unusual cause of complications in cases of FB ingestion. History of FB ingestion may not be elicited, and early diagnosis through radiological imaging and surgical intervention is required to avoid life-threatening complications. The presence of small bowel intussusception due to cotton fiber bezoar just adds to the rarity of this case. This case is probably the first instance of the association of GI perforation and small bowel intussusception due to multiple FB ingestion along with malrotation of the gut.

 
  References Top

1.
Sarmast AH, Showkat HI, Patloo AM, Parray FQ, Lone R, Wani KA. Gastrointestinal tract perforations due to ingested foreign bodies: A review of 21 cases. Br J Med Pract 2012;5: A529.  Back to cited text no. 1
    
2.
Panieri E, Bass DH. The management of ingested foreign bodies in children - A review of 663 cases. Eur J Emerg Med 1995;2:83-7.  Back to cited text no. 2
    
3.
de la Fuente SG, Rice HE. Ingestion of unusual foreign bodies and malrotation: A "perfect storm". Pediatr Surg Int 2006;22:869-72.  Back to cited text no. 3
    
4.
Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, et al. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg 2006;30:372-7.  Back to cited text no. 4
    
5.
ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc 2011;73:1085-91.  Back to cited text no. 5
    
6.
Webb WA. Management of foreign bodies of the upper gastrointestinal tract: Update. Gastrointest Endosc 1995;41:39-51.  Back to cited text no. 6
    
7.
Ginsberg GG. Management of ingested foreign objects and food bolus impactions. Gastrointest Endosc 1995;41:33-8.  Back to cited text no. 7
    
8.
Hesham A-Kader H. Foreign body ingestion: Children like to put objects in their mouth. World J Pediatr 2010;6:301-10.  Back to cited text no. 8
    
9.
Connolly AA, Birchall M, Walsh-Waring GP, Moore-Gillon V. Ingested foreign bodies: Patient-guided localization is a useful clinical tool. Clin Otolaryngol Allied Sci 1992;17:520-4.  Back to cited text no. 9
    
10.
Adams DB. Endoscopic removal of entrapped coins from an intraluminal duodenal diverticulum 20 years after ingestion. Gastrointest Endosc 1986;32:415-6.  Back to cited text no. 10
    
11.
Yao CC, Yang CC, Liew SC, Lin CS. Small bowel perforation caused by a sharp bone: Laparoscopic diagnosis and treatment. Surg Laparosc Endosc Percutan Tech 1999;9:226-7.  Back to cited text no. 11
    
12.
Prasanna BK, Sasikumar K, Gurunandan U, Sreenath GS, Kate V. Rapunzel syndrome: A rare presentation with multiple small intestinal intussusceptions. World J Gastrointest Surg 2013;5:282-4.  Back to cited text no. 12
    
13.
Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF, et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002;55:802-6.  Back to cited text no. 13
    
14.
Matricardi L, Lovati R. Intestinal perforation by a foreign body: Diagnostic usefulness of ultrasonography. J Clin Ultrasound 1992;20:194-6.  Back to cited text no. 14
    
15.
Coulier B, Tancredi MH, Ramboux A. Spiral CT and multidetector-row CT diagnosis of perforation of the small intestine caused by ingested foreign bodies. Eur Radiol 2004;14:1918-25.  Back to cited text no. 15
    
16.
Wooten KE, Hartin CW Jr, Ozgediz DE. Laparoscopic diagnosis of magnetic malrotation with fistula and volvulus. JSLS 2012;16:644-6.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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