BACKGROUND
A 14-month-old boy is brought to the emergency department (ED) by his parents for an evaluation of persistent fever, vomiting, and diarrhea that has lasted for 3 days. The mother states that the child was examined by his pediatrician 2 days before this presentation for a “viral illness“; however, the child has appeared increasingly ill since then. He has become irritable, and he has been minimally active and feeding poorly. He has had a normal stool output and appearance, as well as normal urination frequency. The parents deny observing a runny nose or any coughing, wheezing, or stridor in the patient.
The child lives at home with his parents, he is not in day care, and he has had no contact with people who are sick.
On physical examination, the boy is crying, fussy, and poorly consoled. His vital signs include a rectal temperature of 101°F (38.33°C), a respiratory rate of 32 breaths/min, a blood pressure of 98/56 mm Hg, and a heart rate of 168 bpm. His oxygen saturation is 100% while he is breathing room air. The patient’s weight is 22 lb (10 kg). Palpation reveals diffuse abdominal tenderness without rigidity or guarding. The patient has diffusely hypoactive bowel sounds. His stool is negative for occult blood. The rest of the physical findings are otherwise unremarkable.
{mosimage}Conventional abdominal radiography and computed tomography (CT) scanning are performed (see Images). The laboratory investigation reveals the following results: white blood cell (WBC) count, 19.4 × 109/L, with a predominance of neutrophils; hemoglobin, 8.4 g/dL; hematocrit, 26.6%; platelets, 310 × 109/L; sodium, 136 mmol/L; potassium, 3.8 mmol/L; chlorine, 105 mmol/L; CO2, 20 mmol/L; blood urea nitrogen (BUN), 6 mmol/L; creatinine, 17.7 µmol/L (0.2 mg/dL); and glucose, 4.1 mmol/L (73 mg/dL). The urinalysis shows trace ketones, but the results are otherwise normal.
What is the diagnosis?
{mosimage}HINT
The patient’s symptoms developed approximately 2 days after the mother dropped a box of pins on the carpet at home.
Authors:
Anusuya Mokashi, MD, Department of Medicine Residency, Westchester Medical Center, New York Medical College, Valhalla, NY
Justin Weir, MD, PGY1, Internal Medicine, Danbury Hospital, Danbury CT
Margaret D. Smith, MD, Program Director, Department of Medicine, St. Vincent Catholic Medical Centers (SVCMC), St. Vincent’s Hospital Manhattan, Senior Associate Dean and Associate Professor of Clinical Medicine, New York Medical College, St. Vincent’s Hospital Manhattan
eMedicine Editors:
Erik D. Schraga, MD, Department of Emergency Medicine, Kaiser Permanente, Santa Clara Medical Center, Calif
Rick G. Kulkarni, MD, FACEP, Assistant Professor, Yale School of Medicine, Section of Emergency Medicine, Department of Surgery, Attending Physician, Medical Director, Department of Emergency Services, Yale-New Haven Hospital, CT
ANSWER
Appendiceal perforation by a foreign body (a pin): A foreign body was easily apparent on conventional abdominal radiographs in the right lower quadrant. CT scanning of the abdomen and pelvis revealed a radiopaque pin and a multiloculated fluid collection at the level of the L5 vertebra. The prominent bowel loops superior to the pin likely represented focal ileus.
Ingestion of foreign bodies is relatively common among pediatric patients, who account for approximately 80% of cases. Most objects pass spontaneously; only 1% of all foreign body ingestions require surgical intervention. Among adults, foreign body ingestions most frequently occur in patients with psychiatric disease or in those with a potential secondary gain.
Management of cases of foreign body ingestion depends on the type of object ingested. The objects most commonly ingested are coins, buttons, parts of small toys, pins and thumbtacks, and disk-shaped batteries. For known ingestion of nontoxic, smooth, or small objects, management is conservative because approximately 80-90% of these foreign bodies spontaneously pass though the GI tract without causing harm.
Initial radiographic localization and serial abdominal radiography should be performed every 24-48 hours to monitor the progression of the object until it is passed in stool. Foreign bodies may lodge at any site in the GI tract, but most often they lodge at anatomic sphincters, sites of previous surgery, or areas of narrowing or acute angulation, where they tend to cause obstruction or perforation. The esophagus has several sites of potential obstruction, and perforation at these sites is a particular concern because the rates of related morbidity and mortality are high. The complications of foreign bodies in the esophagus include mediastinitis, lung abscess, pneumothorax, and pericarditis. Approximately 90% of foreign bodies that reach the stomach pass through the remaining GI tract. Most smooth objects pass within the normal bowel transit time.
Because of the high risk of intestinal perforation, urgent intervention is indicated for all patients who have ingested a long, thin, sharp, or stiff foreign body that fails to progress through the GI tract, regardless of the patient’s clinical signs and symptoms. Localization with radiography should be followed by an immediate attempt to remove the object by means of endoscopy, when possible. Emergency laparotomy is indicated if the patient develops abdominal pain or tenderness, fever, or other clinical evidence of perforation, hemorrhaging, or obstruction. Cathartic agents are contraindicated.
Foreign bodies rarely cause complications in the small bowel and colon because they are surrounded by stool and directed to the center of the lumen. In the rare case when the object becomes static in the right lower quadrant (ie, in the terminal ileum, cecum, or appendix), as in this patient, removal by means of colonoscopy should be considered. Other options include laparotomy or laparoscopic removal of the object under fluoroscopic guidance.
The complications of foreign bodies in the distal GI tract include obstruction, abscess formation, peritonitis, adhesions, fistula formation, perforation, and appendicitis. Long, slender, and sharp objects are most likely to injure the mucosa and cause inflammation and perforation, whereas smooth objects lodged in the appendix tend to cause obstructions, leading to acute appendicitis, rupture, and abscess formation. Objects that are heavier than bowel fluid tend to rest in the cecum and gravitate to its most dependent portions. The normal appendix can empty its contents by means of peristalsis; however, the presence of a foreign body, adhesions, or an inflammatory infiltrate can hinder its emptying.
A laparotomy, drainage and excision of an intra-abdominal abscess, as well as an appendectomy and removal of the foreign body, were performed. The appendix was 4.3 cm, and a metallic pin was found piercing the bowel wall (see Image 4). The histology revealed acute serositis with fibrinopurulent exudates in the lumen and on the serosal surface of the appendix.
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