Case Report
J Clin Ultrasound 20:194-196, MarcNApril 1992 CCC 0091-2751/92/030194-03$04.00
0 1992 by John Wiley & Sons, Inc.
Intestinal Perforation by a Foreign Body: Diagnostic Usefulness of Ultrasonography Luigi Matricardi, MD, and Roberta Lovati, MD
Sonography is being more frequently requested as the first modality for the evaluation of abdominal pathology, in many cases allowing a correct diagnosis to be reached without further assessment. We report 1 case in which the sonographic image alone enabled early identification of the origin of an acute abdominal problem caused by organ perforation with no informative history. From the Department of Ultrasound, Len0 Hospital, Brescia, Italy. For reprints contact Luigi Matricardi, MD, Via Battisti 28, 25073 Bovezzo, Brescia, Italy.
CASE REPORT
A 74-year-old woman was admitted to the Division of General Surgery at our hospital complaining of poorly localized right abdominal pain. She had a slight fever of the remittent-intermittent type, of several days’ duration. The patient was in a poor general condition. Objective examination revealed an acute abdomen: sharp pain in all the abdominal quadrants, fever, and positive Blumberg sign. Normocytic anemia, marked elevation of erythrocyte sedimentation rate and a slight leukocytosis were found in laboratory examinations.
FIGURE 1. Ultrasound scan of the abdomen. A subcostal transverse section shows a liver abscess, a fistula connecting the abscess and the anterior colon wall, with a toothpick inside. (L: liver; A: abscess; black arrow: toothpick; C: colon.)
194
INTESTINAL PERFORATION BY A FOREIGN BODY
195
FIGURE 2. (A) Ascending colon enveloped in an inflammatory mass. (B) The probe shows perforation of the anterior colon wall.
Abdominal sonography was then performed, revealing a markedly increased volume of the liver, particularly in the right lobe, where a roundish, hypoechoic area about 2 cm in diameter was detected. Also, the right iliac fossa showed a gross roundish image of likely intestinal origin. This lesion seemed related to the inferior hepatic margin, and a thin, linear, hyperechoic area between it and the inferior hepatic margin suggested a fistula connecting the lesion and the liver (Figure 1A and B). Needle aspiration of the hepatic focal nodule, VOL. 20, NO. 3, MARCHiAPRlL 1992
performed to detect any metastasis, enabled us to collect about 3 ml of purulent substance. The sonographic diagnosis was therefore of an ascending colon disease of unknown etiology with a fistulous tract connected to a hepatic abscess of moderate size. Emergency surgery detected purulent peritonitis at the subhepatic site, caused by perforation of the anterior colon wall by a wooden toothpick. The ascending colon appeared to be enveloped by a large inflammatory mass up to the right flexure (Figure 2). Right hemicolectomy
196
CASE REPORT: MATRICARDI AND LOVATI
was therefore performed with lateral-terminal anastomosis between ileum and transverse colon. After two weeks of routine postoperative hospitalization, the patient was discharged and is still in good health one year after surgery. DISCUSSION
The clinical features of gastrointestinal perforation caused by foreign bodies are quite variable and may simulate different abdominal diseases, such as perforated ulcer of the stomach and duodenum, acute appendicitis, acute colecystitis, and acute diverticulosis.' Accidental swallowing of a foreign body can occur after sudden movement, and therefore it is acknowledged and reported to the physician by the patient himself. However, sometimes the patient does not report the ingestion of a foreign body, especially in the case of accidental swallowing of a toothpick, such as the decorative toothpicks used in food or drink.'" Plain abdomen films are still the main tool for detecting foreign bodies causing intestinal perforation, although several types of objects, including wooden toothpicks and fish bones, are completely transparent. Even barium enema, when practicable, cannot visualize the foreign body when it is already outside the gastrointestinal tract.' In these cases laboratory and plain X-ray findings are rarely of help in making a diagnosis, as they only show peritonitis with the classical radiologic signs of gastrointestinal perforat i ~ n . ~In, ~a ,recent ~ series, half of the cases of foreign body ingestion undergoing surgical procedures were nonradiopaque and only one of them had been accurately diagnosed by preoperative radiological examination.' Radiotransparent foreign bodies can be recognized by computed tomography (CT), as reported by Gonzalez et al. in 2 cases of fishbone perforation,6 and by ultrasonography. Ultrasonic detection of foreign bodies has rarely been described in the l i t e r a t ~ r e mainly ,~ due to its infrequent application when intestinal perforation is suspected. Although ultrasonography is primarily useful for investigating parenchymatous organ pathology and has some limits for gastrointestinal tract disease, it can directly visualize the foreign
body and/or the fistulous tract and the abscess that often follows intestinal perforation. The ability of ultrasonography to detect foreign bodies depends on their material, dimension, shape, and position inside human organs and tissues. However, it can visualize foreign bodies retained within the human body, as described in some in vitro investigation^.^ Although the sonographic picture of a foreign body may be regarded as an instrumental artifact, ultrasonography can definitely diagnose the disease when an abscess or fistulous tract is also seen, and a history of foreign body swallowing is given. In conclusion, our case report shows that abdominal ultrasonography can sometimes be of great help in detecting intestinal perforation by a foreign body, although no study on this subject has yet been carried out. We suggest using ultrasonography when an intestinal perforation by a foreign body is suspected but no object is seen with conventional radiology. Furthermore, such investigations can rule out the presence of other diseases that give a picture of acute abdomen and identify the part of the intestinal tract involved. The possibility of an early etiologic diagnosis of organ perforation by a foreign body through echographic or CT investigation may well afford a reduction of morbidity and mortality associated with such pathology. REFERENCES 1. McCanse DE, Kurchin A, Hinshaw JR: Gastrointestinal foreign bodies. A m J Surg 142:335, 1981. 2. Schwartz JT, Graham DY: Toothpick perforation of the intestines. Ann Surg 185:64, 1977. 3. Leoni GC, Rollo S: Complicanze da ingestione di corpi estranei alimentari. (Clinical picture of foreign bodies ingestion, in Italian.) Chirurgia Oggi 5 9 5 , 1988. 4. Kaufman E, Sommers E: Sigmoid colon perforation: result of accidental swallowing of a toothpick. Oral Surg 58:535, 1984. 5. Chau W, Wu SS, Wang J: Ultrasonic detection of an intraabdominal foreign body. J Clin Ultrasound 13:130, 1985. 6. Gonzalez JG, Gonzalez RR, Patino JV, et al: CT findings in gastrointestinal perforation by ingested fishbones. J CAT 12238, 1988. 7. Suramo I, Pamilo M: Ultrasound examination of foreign bodies. Acta Radio1 Diagn 27:463, 1986.
JOURNAL OF CLINICAL ULTRASOUND
J Clin Ultrasound 20:194-196, MarcNApril 1992 CCC 0091-2751/92/030194-03$04.00
0 1992 by John Wiley & Sons, Inc.
Intestinal Perforation by a Foreign Body: Diagnostic Usefulness of Ultrasonography Luigi Matricardi, MD, and Roberta Lovati, MD
Sonography is being more frequently requested as the first modality for the evaluation of abdominal pathology, in many cases allowing a correct diagnosis to be reached without further assessment. We report 1 case in which the sonographic image alone enabled early identification of the origin of an acute abdominal problem caused by organ perforation with no informative history. From the Department of Ultrasound, Len0 Hospital, Brescia, Italy. For reprints contact Luigi Matricardi, MD, Via Battisti 28, 25073 Bovezzo, Brescia, Italy.
CASE REPORT
A 74-year-old woman was admitted to the Division of General Surgery at our hospital complaining of poorly localized right abdominal pain. She had a slight fever of the remittent-intermittent type, of several days’ duration. The patient was in a poor general condition. Objective examination revealed an acute abdomen: sharp pain in all the abdominal quadrants, fever, and positive Blumberg sign. Normocytic anemia, marked elevation of erythrocyte sedimentation rate and a slight leukocytosis were found in laboratory examinations.
FIGURE 1. Ultrasound scan of the abdomen. A subcostal transverse section shows a liver abscess, a fistula connecting the abscess and the anterior colon wall, with a toothpick inside. (L: liver; A: abscess; black arrow: toothpick; C: colon.)
194
INTESTINAL PERFORATION BY A FOREIGN BODY
195
FIGURE 2. (A) Ascending colon enveloped in an inflammatory mass. (B) The probe shows perforation of the anterior colon wall.
Abdominal sonography was then performed, revealing a markedly increased volume of the liver, particularly in the right lobe, where a roundish, hypoechoic area about 2 cm in diameter was detected. Also, the right iliac fossa showed a gross roundish image of likely intestinal origin. This lesion seemed related to the inferior hepatic margin, and a thin, linear, hyperechoic area between it and the inferior hepatic margin suggested a fistula connecting the lesion and the liver (Figure 1A and B). Needle aspiration of the hepatic focal nodule, VOL. 20, NO. 3, MARCHiAPRlL 1992
performed to detect any metastasis, enabled us to collect about 3 ml of purulent substance. The sonographic diagnosis was therefore of an ascending colon disease of unknown etiology with a fistulous tract connected to a hepatic abscess of moderate size. Emergency surgery detected purulent peritonitis at the subhepatic site, caused by perforation of the anterior colon wall by a wooden toothpick. The ascending colon appeared to be enveloped by a large inflammatory mass up to the right flexure (Figure 2). Right hemicolectomy
196
CASE REPORT: MATRICARDI AND LOVATI
was therefore performed with lateral-terminal anastomosis between ileum and transverse colon. After two weeks of routine postoperative hospitalization, the patient was discharged and is still in good health one year after surgery. DISCUSSION
The clinical features of gastrointestinal perforation caused by foreign bodies are quite variable and may simulate different abdominal diseases, such as perforated ulcer of the stomach and duodenum, acute appendicitis, acute colecystitis, and acute diverticulosis.' Accidental swallowing of a foreign body can occur after sudden movement, and therefore it is acknowledged and reported to the physician by the patient himself. However, sometimes the patient does not report the ingestion of a foreign body, especially in the case of accidental swallowing of a toothpick, such as the decorative toothpicks used in food or drink.'" Plain abdomen films are still the main tool for detecting foreign bodies causing intestinal perforation, although several types of objects, including wooden toothpicks and fish bones, are completely transparent. Even barium enema, when practicable, cannot visualize the foreign body when it is already outside the gastrointestinal tract.' In these cases laboratory and plain X-ray findings are rarely of help in making a diagnosis, as they only show peritonitis with the classical radiologic signs of gastrointestinal perforat i ~ n . ~In, ~a ,recent ~ series, half of the cases of foreign body ingestion undergoing surgical procedures were nonradiopaque and only one of them had been accurately diagnosed by preoperative radiological examination.' Radiotransparent foreign bodies can be recognized by computed tomography (CT), as reported by Gonzalez et al. in 2 cases of fishbone perforation,6 and by ultrasonography. Ultrasonic detection of foreign bodies has rarely been described in the l i t e r a t ~ r e mainly ,~ due to its infrequent application when intestinal perforation is suspected. Although ultrasonography is primarily useful for investigating parenchymatous organ pathology and has some limits for gastrointestinal tract disease, it can directly visualize the foreign
body and/or the fistulous tract and the abscess that often follows intestinal perforation. The ability of ultrasonography to detect foreign bodies depends on their material, dimension, shape, and position inside human organs and tissues. However, it can visualize foreign bodies retained within the human body, as described in some in vitro investigation^.^ Although the sonographic picture of a foreign body may be regarded as an instrumental artifact, ultrasonography can definitely diagnose the disease when an abscess or fistulous tract is also seen, and a history of foreign body swallowing is given. In conclusion, our case report shows that abdominal ultrasonography can sometimes be of great help in detecting intestinal perforation by a foreign body, although no study on this subject has yet been carried out. We suggest using ultrasonography when an intestinal perforation by a foreign body is suspected but no object is seen with conventional radiology. Furthermore, such investigations can rule out the presence of other diseases that give a picture of acute abdomen and identify the part of the intestinal tract involved. The possibility of an early etiologic diagnosis of organ perforation by a foreign body through echographic or CT investigation may well afford a reduction of morbidity and mortality associated with such pathology. REFERENCES 1. McCanse DE, Kurchin A, Hinshaw JR: Gastrointestinal foreign bodies. A m J Surg 142:335, 1981. 2. Schwartz JT, Graham DY: Toothpick perforation of the intestines. Ann Surg 185:64, 1977. 3. Leoni GC, Rollo S: Complicanze da ingestione di corpi estranei alimentari. (Clinical picture of foreign bodies ingestion, in Italian.) Chirurgia Oggi 5 9 5 , 1988. 4. Kaufman E, Sommers E: Sigmoid colon perforation: result of accidental swallowing of a toothpick. Oral Surg 58:535, 1984. 5. Chau W, Wu SS, Wang J: Ultrasonic detection of an intraabdominal foreign body. J Clin Ultrasound 13:130, 1985. 6. Gonzalez JG, Gonzalez RR, Patino JV, et al: CT findings in gastrointestinal perforation by ingested fishbones. J CAT 12238, 1988. 7. Suramo I, Pamilo M: Ultrasound examination of foreign bodies. Acta Radio1 Diagn 27:463, 1986.
JOURNAL OF CLINICAL ULTRASOUND
