BJR Received: 26 January 2015
© 2015 The Authors. Published by the British Institute of Radiology Revised: 16 March 2015
Accepted: 31 March 2015
doi: 10.1259/bjr.20150086
Cite this article as: Kuzmich S, Burke CJ, Harvey CJ, Kuzmich T, Andrews J, Reading N, et al. Perforation of gastrointestinal tract by poorly conspicuous ingested foreign bodies: radiological diagnosis. Br J Radiol 2015;88:20150086.
PICTORIAL REVIEW
Perforation of gastrointestinal tract by poorly conspicuous ingested foreign bodies: radiological diagnosis 1
S KUZMICH, FRCR, 2C J BURKE, FRCR, 3C J HARVEY, FRCR, 4T KUZMICH, MD, 1J ANDREWS, FRCR, 1N READING, FRCR, S PATHAK, FRCR and 1N PATEL, MBBS
1 1
Radiology Department, Whipps Cross University Hospital, London, UK Department of Radiology, Guy’s and St Thomas’ Hospitals, London, UK 3 Imaging Department, Hammersmith Hospital, London, UK 4 Radiology Department, Newham University Hospital, London, UK 2
Address correspondence to: Dr Siarhei Kuzmich E-mail: [email protected]
ABSTRACT Perforation of gastrointestinal (GI) tract by ingested bone fragments, toothpicks and dentures is rare but remains an important life-threatening condition, and the outcomes are poorer when the diagnosis is delayed. Invariably, clinical and radiographic diagnosis is difficult as most patients will have no recollection of ingesting a foreign body, whereas these subtle objects are often not visible on radiographs. In search for the diagnosis, CT is the modality of choice, but ultrasound imaging may be first requested in patients presenting with symptoms of acute appendicitis, cholecystitis, pyelonephritis or pelvic inflammatory disease when an ingested foreign body is not considered. Although ultrasound has limited value in depicting a foreign body, it can frequently uncover secondary signs of perforation. However, the rarity of this condition combined with non-specific clinical presentation and the propensity of these small perforating objects to be subtle makes establishing the correct diagnosis by the radiologist challenging. Therefore, understanding of the appearances of GI perforation seen on CT images or general abdominal ultrasound will aid the radiologist in the diagnosis of this important yet often unsuspected condition. This will lead to earlier diagnosis and surgical management. In this article, we illustrate the spectrum of CT, radiographic and ultrasound imaging features seen in GI perforation caused by swallowed bone fragments, toothpicks, cocktail sticks and dentures.
A variety of foreign bodies are ingested unintentionally during rapid eating, particularly by persons with reduced palate sensitivity caused by dentures and by those who abuse alcohol and drugs. Young children, elderly and mentally challenged persons are usually at a higher risk. Fortunately, perforation is rare. ,1% of ingested foreign bodies are believed to cause perforation of the gastrointestinal (GI) tract.1 Ingested foreign bodies may perforate anywhere along the GI tract but are more often reported to lodge in the hypopharynx or upper oesophagus, or to impact at areas of narrowing from pre-existing strictures or sites of anatomic angulation in the duodenal loop, duodenojejunal junction, ileocaecal valve and appendix. The most common locations for perforation of the lower GI tract are in the ileocaecal and rectosigmoid regions.2 Clinical presentation is variable. Patients with foreign body impacted in the oesophagus will present with dysphagia and
odynophagia. When perforation of the bowel has occurred, many patients will show signs of localized peritonitis. Localized abdominal symptoms may mimic various inflammatory conditions depending on the site of perforation, patient’s medical history and age. At the other end of the spectrum, foreign body perforation may be incomplete, subacute or chronic with the object very slowly eroding through the bowel wall, producing a chronic inflammatory process that has few symptoms.1,2 Such cases are sometimes uncovered incidentally months or years later. Linear foreign objects can migrate into adjacent organs with resultant fistulation, abscess formation or septicaemia.3,4 Perforating fish bones, chicken bone fragments, toothpicks, cocktail sticks and dentures often present a diagnostic dilemma. Usually, such subtle foreign bodies are either inherently non-opaque or insufficiently opaque to be visible on radiographs, while most patients will have no recollection of ingesting a foreign body.1,2 Other poorly conspicuous ingested foreign bodies such as plastic bread bag clips, mussel and crab
BJR
S Kuzmich et al
Figure 1. Minimal pneumoperitoneum. Right intercostal ultrasound image using 3.5-MHz curvilinear transducer depicts a small bubble of free air (arrow) on the liver surface with posterior comet-tail artefact (arrowhead). Inset shows corresponding axial CT image.
Figure 3. Fish bone perforating proximal oesophagus. (a) Softtissue lateral radiograph of the neck shows pre-vertebral softtissue swelling but no foreign body is visible. (b) Subsequent CT image reveals a dense linear foreign body (arrow) proven to be a fishbone perforating proximal oesophagus. Pockets of gas (arrowhead) are seen next to the oesophagus.
which is difficult to detect and which the radiologist should be aware of, as Coulier et al5 have recently described.
shell fragments have also been reported to cause GI tract perforation. Ingested blister pill pack is another example of seemingly innocuous but potentially dangerous perforating foreign body, Figure 2. An ingested foreign body (arrow) presumed to be a transiting fish bone is incidentally seen in the descending colon on this unenhanced axial CT image. The patient had unfilleted fish the day previously but remained asymptomatic on subsequent clinical follow-up a year later.
CT is generally chosen as the next imaging test and is the modality of choice. Ultrasound is often requested to evaluate abdominal symptoms when ingested foreign body is not considered. Diagnostic challenges arise from the low level of suspicion of the radiologist and referring clinician combined with confusing clinical presentation and subtle appearances of the perforating objects. Therefore, in order to encourage awareness, we illustrate the spectrum of imaging features seen in perforation of the oesophagus, duodenum, small and large bowel caused by ingested bones, toothpicks, cocktail sticks and dentures. INDIRECT SIGNS OF PERFORATION Ancillary signs that point to perforation include extraluminal free gas, localized inflammatory change, collection of fluid or abscess and a segment of moderately thickened bowel. Analysis of these secondary signs is important and will often point to the bowel segment where a perforation has occurred. Pneumoperitoneum may be present but is often minimal or absent. Localized perforation with abscess formation is common. On sonography, small amounts of free gas are seen as brightly echogenic foci or lines situated on the liver surface or beneath the anterior abdominal wall with the patient supine. They produce characteristic ring-down or comet-tail artefacts (Figure 1). With careful technique, ultrasound can detect a minimal amount of free gas equating to a single bubble because of its exclusive ability to produce bright echoes and artefacts.6 However, the diagnostic quality of ultrasound can be compromised by obesity, faecal loading, pain and availability of expertise for this type of evaluation. CT allows accurate detection of free intraperitoneal or extraluminal air. FISH BONES With growing utilization of CT, ingested fish bones are more frequently seen as dense linear objects situated within the bowel lumen. They are thought of as incidental when signs of impaction and perforation are absent (Figure 2).
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Figure 4. Fish bone perforating fourth part of the duodenum in a 55-year-old male. Multiplanar reformatted coronal image depicts a linear density (arrow) perforating the duodenal wall and pockets of free extraluminal gas (arrowhead) nearby.
Figure 6. Fish bone perforation of the sigmoid colon. Intravenous contrast-enhanced axial CT image shows a fish bone (arrow) perforating the sigmoid colon. Small volume pneumoperitoneum was present.
In the neck, a soft-tissue lateral radiograph may localize a calcified fish bone, but many bones are not visible on a radiograph. Indirect signs such as pre-vertebral soft-tissue swelling or gas in
an abscess will prompt CT imaging to clarify the diagnosis (Figure 3).
Figure 5. Fish bone perforating the jejunum in a 62-year-old male who presented with acute colicky left abdominal pain and was suspected of having renal colic. Unenhanced axial CT image depicts a curvilinear foreign body impacted in the thickened jejunum. One end of the fish bone (arrow) is projecting through the bowel wall. No fluid collection or free gas was seen in this case of early perforation.
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Abdominal radiographs are usually unrevealing. On occasion, ultrasound may demonstrate a perforating fish bone, but this is
Figure 7. Impacted chicken bone (arrow) anterior to C7 and T1 vertebrae.
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Figure 8. Turkey bone perforating the sigmoid colon. (a) Frontal pelvic radiograph shows a linear foreign body (arrow) projecting on the left pelvis. (b) Subsequent sagittal reformatted CT image using bone window depicts the bone (arrow) perforating the sigmoid colon.
often difficult.7 More often, ultrasound will detect indirect signs of perforation and thus expedite CT imaging, which will reveal the perforation. Perforating fish bones may be seen impacted in the bowel wall or lying completely outside of the bowel. Many fish bones are small and thin which makes them difficult to detect. A careful inspection using multiplanar reformatting will help uncover a small fish bone (Figure 4).8 Certain fish bones, however, can be much more conspicuous and therefore difficult to overlook (Figure 5). Uncovering a subtle perforating fish bone in the sigmoid colon can be challenging in the setting of faecal loading and pre-existing diverticulosis, particularly on poorer quality CT studies, so careful inspection of the suspected perforation site is necessary (Figure 6). Pre-operative CT diagnosis of a perforating fish bone is often reported to be difficult. As Goh et al9 have described, the difficulties may arise out of limited radio-opacity of certain types of
fish bones making them hard to perceive, poor quality CT studies, overreliance on thick slice studies, use of oral contrast and, in some cases, lack of awareness by the interpreting radiologist. CHICKEN BONE AND OTHER BONE FRAGMENTS Unlike fish bones, chicken bones tend to be substantially more radio-opaque.1 A soft-tissue lateral radiograph of the neck will often localize an impacted bone (Figure 7). Depending on the opacity of the bone and quality of the image, an abdominal radiograph may also show an ingested bone, but CT will be needed to assess if the bone has perforated (Figure 8). Nonetheless, smaller bone fragments may be subtle presenting a challenge. Ultrasound can detect a linear bright object of peculiar geometry piercing the bowel wall (Figure 9a). CT will further evaluate the perforating object and the extent of
Figure 9. Chicken bone perforating the jejunum in a 64-year-old male suspected of having colonic diverticulitis. (a) Sonogram of the left flank with a 6-MHz transducer shows a fluid collection (asterisk) next to a thickened small bowel (J) and a bright curvilinear structure (arrow) piercing the bowel wall. (b) Corresponding multiplanar reformatted unenhanced CT image displays a perforating foreign body (arrow), which was found to be a chicken bone fragment that had perforated the jejunum.
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Figure 10. Toothpick perforation of the ileum in a 36-year-old male who presented with acute right lower quadrant pain and was suspected of having acute appendicitis. (a) Intravenous contrast-enhanced coronal CT image depicts a subtle dense linear object (arrow), which was considered suspicious for a foreign body. (b) Subsequent unenhanced coronal CT image improves perception of a linear foreign body (arrow) perforating the ileum. Toothpick perforating the ileal wall and a small interloop abscess were found at surgery.
associated complications as required for pre-operative planning (Figure 9b). TOOTHPICKS AND COCKTAIL STICKS Of all ingested foreign objects described here, toothpicks and cocktail sticks have the greatest propensity for migrating into any of the adjacent organs leading to fistulation and abscess formation.10 Depending on the type of wood it happens to be made of, a toothpick can be difficult to perceive on CT, particularly when oral or intravenous contrast is used (Figure 10a). When doubt exists, a repeat non-contrast CT study will improve the diagnostic confidence (Figure 10b). As with fish bones, careful inspection using multiplanar and, if necessary (to persuade the surgeon), three-dimensional reconstructions will often be useful (Figure 11). Luckily, certain wooden sticks are quite radiodense allowing for an easy discovery (Figure 12). Successful attempts have been made to use ultrasound for detecting ingested toothpicks, but CT remains the mainstay of the diagnosis.
DENTURES Contemporary dental prostheses are made of radiolucent composite resin that makes them invisible on radiographs, unless they include metal framework as in partial dentures which may contain wire retainers or clasps anchoring replacement teeth to the adjacent crowns. This type of wire-containing dentures has
Figure 12. Cocktail stick perforating the ileum in a 40-year-old male with paraumbilical pain of 5 days and fever. Multiplanar reformatted CT image shows a dense linear foreign body (arrow), which was seen lying in the fluid collection next to a thickened ileal loop. No free gas was present. Surgery revealed a cocktail stick in an interloop abscess and perforated ileum.
Figure 11. Toothpick perforating the ileum. (a) Multiplanar reformatted intravenous contrast-enhanced axial CT image and (b) three-dimensional reformatted image displaying the full length of the perforating foreign body (arrows), which was found to be a toothpick.
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Figure 13. Perforation of proximal oesophagus by an ingested broken partial denture in a 53-year-old male with 6-days history of odynophagia. (a) A curved wire (arrow) projecting at T1 level is visible on careful inspection of this frontal chest radiograph but was initially not recognized on presentation. (b) Axial contrast-enhanced CT image at T1 level and (c) multiplanar reformatted CT image depict a gas pocket (arrowhead) and a free end of the dental wire (arrows) perforating through the oesophageal wall.
been reported to have higher tendency to impact and perforate in the GI tract.11 The risk of perforation is increased when ingested dentures contain a broken wire with a sharp pointy end, as in our case (Figure 13). CONCLUSION The clinical and radiological diagnosis of GI perforation caused by poorly conspicuous ingested foreign bodies is challenging. Familiarity with the characteristic radiographic
and CT manifestations combined with careful interpretation using multiplanar reformatting will facilitate the correct diagnosis. Because ultrasound is also frequently chosen in patients with localized abdominal symptoms, understanding of the appearances of bowel perforation seen during general abdominal sonography will aid the radiologist in the diagnosis of this important yet often unsuspected cause of abdominal pain. This will lead to earlier diagnosis and appropriate surgical management.
REFERENCES 1.
2.
3.
4.
Hunter TB, Taljanovic MS. Foreign bodies. Radiographics 2003; 23: 731–57. doi: 10.1148/ rg.233025137 Rodr´ıguez-Hermosa JI, Codina-Cazador A, Sirvent JM, Mart´ın A, Giron`es J, Garsot E. Surgically treated perforations of the gastrointestinal tract caused by ingested foreign bodies. Colorectal Dis 2008; 10: 701–7. doi: 10.1111/j.1463-1318.2007.01401.x Goh BK, Yong WS, Yeo AW. Pancreatic and hepatic abscess secondary to fish bone perforation of the duodenum. Dig Dis Sci 2005; 50: 1103–6. doi: 10.1007/s10620-0052712-8 Brandão D, Canedo A, Maia M, Ferreira J, Vaz G. Duodenocaval fistula as a result of a fish bone perforation. J Vasc Surg 2010; 51: 1276–8. doi: 10.1016/j.jvs.2009.12.049
6 of 6 birpublications.org/bjr
5.
6.
7.
8.
Coulier B, Rubay R, Van den Broeck S, Azar AR, Maldague P, Mailleux P, et al. Perforation of the gastrointestinal tract caused by inadvertent ingestion of blister pill packs: report of two cases diagnosed by MDCT with emphasis on maximal intensity and volume rendering reformations. Abdom Imaging 2014; 39: 685–93. doi: 10.1007/s00261-014-0120-2 Kuzmich S, Harvey CJ, Fascia DT, Kuzmich T, Neriman D, Basit R, et al. Perforated pyloroduodenal peptic ulcer and sonography. AJR Am J Roentgenol 2012; 199: W587–594. doi: 10.2214/AJR.11.8292 Coulier B. Diagnostic ultrasonography of perforating foreign bodies of the digestive tract. [In French.] J Belge Radiol 1997; 80: 1–5. 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. doi: 10.1007/s00330-004-2430-1 9. Goh BK, Tan YM, Lin SE, Chow PK, Cheah FK, Ooi LL, et al. CT in the preoperative diagnosis of fish bone perforation of the gastrointestinal tract. AJR Am J Roentgenol 2006; 187: 710–14. doi: 10.2214/AJR.05.0178 10. Steinbach C, Stockmann M, Jara M, Bednarsh J, Lock JF. Accidentally ingested toothpicks causing severe gastrointestinal injury: a practical guideline for diagnosis and therapy based on 136 case reports. World J Surg 2014; 38: 371–7. doi: 10.1007/s00268013-2307-z 11. Hashmi S, Walter J, Smith W, Latis S. Swallowed partial dentures. J R Soc Med 2004; 97: 72–5.
Br J Radiol;88:20150086
© 2015 The Authors. Published by the British Institute of Radiology Revised: 16 March 2015
Accepted: 31 March 2015
doi: 10.1259/bjr.20150086
Cite this article as: Kuzmich S, Burke CJ, Harvey CJ, Kuzmich T, Andrews J, Reading N, et al. Perforation of gastrointestinal tract by poorly conspicuous ingested foreign bodies: radiological diagnosis. Br J Radiol 2015;88:20150086.
PICTORIAL REVIEW
Perforation of gastrointestinal tract by poorly conspicuous ingested foreign bodies: radiological diagnosis 1
S KUZMICH, FRCR, 2C J BURKE, FRCR, 3C J HARVEY, FRCR, 4T KUZMICH, MD, 1J ANDREWS, FRCR, 1N READING, FRCR, S PATHAK, FRCR and 1N PATEL, MBBS
1 1
Radiology Department, Whipps Cross University Hospital, London, UK Department of Radiology, Guy’s and St Thomas’ Hospitals, London, UK 3 Imaging Department, Hammersmith Hospital, London, UK 4 Radiology Department, Newham University Hospital, London, UK 2
Address correspondence to: Dr Siarhei Kuzmich E-mail: [email protected]
ABSTRACT Perforation of gastrointestinal (GI) tract by ingested bone fragments, toothpicks and dentures is rare but remains an important life-threatening condition, and the outcomes are poorer when the diagnosis is delayed. Invariably, clinical and radiographic diagnosis is difficult as most patients will have no recollection of ingesting a foreign body, whereas these subtle objects are often not visible on radiographs. In search for the diagnosis, CT is the modality of choice, but ultrasound imaging may be first requested in patients presenting with symptoms of acute appendicitis, cholecystitis, pyelonephritis or pelvic inflammatory disease when an ingested foreign body is not considered. Although ultrasound has limited value in depicting a foreign body, it can frequently uncover secondary signs of perforation. However, the rarity of this condition combined with non-specific clinical presentation and the propensity of these small perforating objects to be subtle makes establishing the correct diagnosis by the radiologist challenging. Therefore, understanding of the appearances of GI perforation seen on CT images or general abdominal ultrasound will aid the radiologist in the diagnosis of this important yet often unsuspected condition. This will lead to earlier diagnosis and surgical management. In this article, we illustrate the spectrum of CT, radiographic and ultrasound imaging features seen in GI perforation caused by swallowed bone fragments, toothpicks, cocktail sticks and dentures.
A variety of foreign bodies are ingested unintentionally during rapid eating, particularly by persons with reduced palate sensitivity caused by dentures and by those who abuse alcohol and drugs. Young children, elderly and mentally challenged persons are usually at a higher risk. Fortunately, perforation is rare. ,1% of ingested foreign bodies are believed to cause perforation of the gastrointestinal (GI) tract.1 Ingested foreign bodies may perforate anywhere along the GI tract but are more often reported to lodge in the hypopharynx or upper oesophagus, or to impact at areas of narrowing from pre-existing strictures or sites of anatomic angulation in the duodenal loop, duodenojejunal junction, ileocaecal valve and appendix. The most common locations for perforation of the lower GI tract are in the ileocaecal and rectosigmoid regions.2 Clinical presentation is variable. Patients with foreign body impacted in the oesophagus will present with dysphagia and
odynophagia. When perforation of the bowel has occurred, many patients will show signs of localized peritonitis. Localized abdominal symptoms may mimic various inflammatory conditions depending on the site of perforation, patient’s medical history and age. At the other end of the spectrum, foreign body perforation may be incomplete, subacute or chronic with the object very slowly eroding through the bowel wall, producing a chronic inflammatory process that has few symptoms.1,2 Such cases are sometimes uncovered incidentally months or years later. Linear foreign objects can migrate into adjacent organs with resultant fistulation, abscess formation or septicaemia.3,4 Perforating fish bones, chicken bone fragments, toothpicks, cocktail sticks and dentures often present a diagnostic dilemma. Usually, such subtle foreign bodies are either inherently non-opaque or insufficiently opaque to be visible on radiographs, while most patients will have no recollection of ingesting a foreign body.1,2 Other poorly conspicuous ingested foreign bodies such as plastic bread bag clips, mussel and crab
BJR
S Kuzmich et al
Figure 1. Minimal pneumoperitoneum. Right intercostal ultrasound image using 3.5-MHz curvilinear transducer depicts a small bubble of free air (arrow) on the liver surface with posterior comet-tail artefact (arrowhead). Inset shows corresponding axial CT image.
Figure 3. Fish bone perforating proximal oesophagus. (a) Softtissue lateral radiograph of the neck shows pre-vertebral softtissue swelling but no foreign body is visible. (b) Subsequent CT image reveals a dense linear foreign body (arrow) proven to be a fishbone perforating proximal oesophagus. Pockets of gas (arrowhead) are seen next to the oesophagus.
which is difficult to detect and which the radiologist should be aware of, as Coulier et al5 have recently described.
shell fragments have also been reported to cause GI tract perforation. Ingested blister pill pack is another example of seemingly innocuous but potentially dangerous perforating foreign body, Figure 2. An ingested foreign body (arrow) presumed to be a transiting fish bone is incidentally seen in the descending colon on this unenhanced axial CT image. The patient had unfilleted fish the day previously but remained asymptomatic on subsequent clinical follow-up a year later.
CT is generally chosen as the next imaging test and is the modality of choice. Ultrasound is often requested to evaluate abdominal symptoms when ingested foreign body is not considered. Diagnostic challenges arise from the low level of suspicion of the radiologist and referring clinician combined with confusing clinical presentation and subtle appearances of the perforating objects. Therefore, in order to encourage awareness, we illustrate the spectrum of imaging features seen in perforation of the oesophagus, duodenum, small and large bowel caused by ingested bones, toothpicks, cocktail sticks and dentures. INDIRECT SIGNS OF PERFORATION Ancillary signs that point to perforation include extraluminal free gas, localized inflammatory change, collection of fluid or abscess and a segment of moderately thickened bowel. Analysis of these secondary signs is important and will often point to the bowel segment where a perforation has occurred. Pneumoperitoneum may be present but is often minimal or absent. Localized perforation with abscess formation is common. On sonography, small amounts of free gas are seen as brightly echogenic foci or lines situated on the liver surface or beneath the anterior abdominal wall with the patient supine. They produce characteristic ring-down or comet-tail artefacts (Figure 1). With careful technique, ultrasound can detect a minimal amount of free gas equating to a single bubble because of its exclusive ability to produce bright echoes and artefacts.6 However, the diagnostic quality of ultrasound can be compromised by obesity, faecal loading, pain and availability of expertise for this type of evaluation. CT allows accurate detection of free intraperitoneal or extraluminal air. FISH BONES With growing utilization of CT, ingested fish bones are more frequently seen as dense linear objects situated within the bowel lumen. They are thought of as incidental when signs of impaction and perforation are absent (Figure 2).
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Figure 4. Fish bone perforating fourth part of the duodenum in a 55-year-old male. Multiplanar reformatted coronal image depicts a linear density (arrow) perforating the duodenal wall and pockets of free extraluminal gas (arrowhead) nearby.
Figure 6. Fish bone perforation of the sigmoid colon. Intravenous contrast-enhanced axial CT image shows a fish bone (arrow) perforating the sigmoid colon. Small volume pneumoperitoneum was present.
In the neck, a soft-tissue lateral radiograph may localize a calcified fish bone, but many bones are not visible on a radiograph. Indirect signs such as pre-vertebral soft-tissue swelling or gas in
an abscess will prompt CT imaging to clarify the diagnosis (Figure 3).
Figure 5. Fish bone perforating the jejunum in a 62-year-old male who presented with acute colicky left abdominal pain and was suspected of having renal colic. Unenhanced axial CT image depicts a curvilinear foreign body impacted in the thickened jejunum. One end of the fish bone (arrow) is projecting through the bowel wall. No fluid collection or free gas was seen in this case of early perforation.
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Abdominal radiographs are usually unrevealing. On occasion, ultrasound may demonstrate a perforating fish bone, but this is
Figure 7. Impacted chicken bone (arrow) anterior to C7 and T1 vertebrae.
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Figure 8. Turkey bone perforating the sigmoid colon. (a) Frontal pelvic radiograph shows a linear foreign body (arrow) projecting on the left pelvis. (b) Subsequent sagittal reformatted CT image using bone window depicts the bone (arrow) perforating the sigmoid colon.
often difficult.7 More often, ultrasound will detect indirect signs of perforation and thus expedite CT imaging, which will reveal the perforation. Perforating fish bones may be seen impacted in the bowel wall or lying completely outside of the bowel. Many fish bones are small and thin which makes them difficult to detect. A careful inspection using multiplanar reformatting will help uncover a small fish bone (Figure 4).8 Certain fish bones, however, can be much more conspicuous and therefore difficult to overlook (Figure 5). Uncovering a subtle perforating fish bone in the sigmoid colon can be challenging in the setting of faecal loading and pre-existing diverticulosis, particularly on poorer quality CT studies, so careful inspection of the suspected perforation site is necessary (Figure 6). Pre-operative CT diagnosis of a perforating fish bone is often reported to be difficult. As Goh et al9 have described, the difficulties may arise out of limited radio-opacity of certain types of
fish bones making them hard to perceive, poor quality CT studies, overreliance on thick slice studies, use of oral contrast and, in some cases, lack of awareness by the interpreting radiologist. CHICKEN BONE AND OTHER BONE FRAGMENTS Unlike fish bones, chicken bones tend to be substantially more radio-opaque.1 A soft-tissue lateral radiograph of the neck will often localize an impacted bone (Figure 7). Depending on the opacity of the bone and quality of the image, an abdominal radiograph may also show an ingested bone, but CT will be needed to assess if the bone has perforated (Figure 8). Nonetheless, smaller bone fragments may be subtle presenting a challenge. Ultrasound can detect a linear bright object of peculiar geometry piercing the bowel wall (Figure 9a). CT will further evaluate the perforating object and the extent of
Figure 9. Chicken bone perforating the jejunum in a 64-year-old male suspected of having colonic diverticulitis. (a) Sonogram of the left flank with a 6-MHz transducer shows a fluid collection (asterisk) next to a thickened small bowel (J) and a bright curvilinear structure (arrow) piercing the bowel wall. (b) Corresponding multiplanar reformatted unenhanced CT image displays a perforating foreign body (arrow), which was found to be a chicken bone fragment that had perforated the jejunum.
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Figure 10. Toothpick perforation of the ileum in a 36-year-old male who presented with acute right lower quadrant pain and was suspected of having acute appendicitis. (a) Intravenous contrast-enhanced coronal CT image depicts a subtle dense linear object (arrow), which was considered suspicious for a foreign body. (b) Subsequent unenhanced coronal CT image improves perception of a linear foreign body (arrow) perforating the ileum. Toothpick perforating the ileal wall and a small interloop abscess were found at surgery.
associated complications as required for pre-operative planning (Figure 9b). TOOTHPICKS AND COCKTAIL STICKS Of all ingested foreign objects described here, toothpicks and cocktail sticks have the greatest propensity for migrating into any of the adjacent organs leading to fistulation and abscess formation.10 Depending on the type of wood it happens to be made of, a toothpick can be difficult to perceive on CT, particularly when oral or intravenous contrast is used (Figure 10a). When doubt exists, a repeat non-contrast CT study will improve the diagnostic confidence (Figure 10b). As with fish bones, careful inspection using multiplanar and, if necessary (to persuade the surgeon), three-dimensional reconstructions will often be useful (Figure 11). Luckily, certain wooden sticks are quite radiodense allowing for an easy discovery (Figure 12). Successful attempts have been made to use ultrasound for detecting ingested toothpicks, but CT remains the mainstay of the diagnosis.
DENTURES Contemporary dental prostheses are made of radiolucent composite resin that makes them invisible on radiographs, unless they include metal framework as in partial dentures which may contain wire retainers or clasps anchoring replacement teeth to the adjacent crowns. This type of wire-containing dentures has
Figure 12. Cocktail stick perforating the ileum in a 40-year-old male with paraumbilical pain of 5 days and fever. Multiplanar reformatted CT image shows a dense linear foreign body (arrow), which was seen lying in the fluid collection next to a thickened ileal loop. No free gas was present. Surgery revealed a cocktail stick in an interloop abscess and perforated ileum.
Figure 11. Toothpick perforating the ileum. (a) Multiplanar reformatted intravenous contrast-enhanced axial CT image and (b) three-dimensional reformatted image displaying the full length of the perforating foreign body (arrows), which was found to be a toothpick.
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Figure 13. Perforation of proximal oesophagus by an ingested broken partial denture in a 53-year-old male with 6-days history of odynophagia. (a) A curved wire (arrow) projecting at T1 level is visible on careful inspection of this frontal chest radiograph but was initially not recognized on presentation. (b) Axial contrast-enhanced CT image at T1 level and (c) multiplanar reformatted CT image depict a gas pocket (arrowhead) and a free end of the dental wire (arrows) perforating through the oesophageal wall.
been reported to have higher tendency to impact and perforate in the GI tract.11 The risk of perforation is increased when ingested dentures contain a broken wire with a sharp pointy end, as in our case (Figure 13). CONCLUSION The clinical and radiological diagnosis of GI perforation caused by poorly conspicuous ingested foreign bodies is challenging. Familiarity with the characteristic radiographic
and CT manifestations combined with careful interpretation using multiplanar reformatting will facilitate the correct diagnosis. Because ultrasound is also frequently chosen in patients with localized abdominal symptoms, understanding of the appearances of bowel perforation seen during general abdominal sonography will aid the radiologist in the diagnosis of this important yet often unsuspected cause of abdominal pain. This will lead to earlier diagnosis and appropriate surgical management.
REFERENCES 1.
2.
3.
4.
Hunter TB, Taljanovic MS. Foreign bodies. Radiographics 2003; 23: 731–57. doi: 10.1148/ rg.233025137 Rodr´ıguez-Hermosa JI, Codina-Cazador A, Sirvent JM, Mart´ın A, Giron`es J, Garsot E. Surgically treated perforations of the gastrointestinal tract caused by ingested foreign bodies. Colorectal Dis 2008; 10: 701–7. doi: 10.1111/j.1463-1318.2007.01401.x Goh BK, Yong WS, Yeo AW. Pancreatic and hepatic abscess secondary to fish bone perforation of the duodenum. Dig Dis Sci 2005; 50: 1103–6. doi: 10.1007/s10620-0052712-8 Brandão D, Canedo A, Maia M, Ferreira J, Vaz G. Duodenocaval fistula as a result of a fish bone perforation. J Vasc Surg 2010; 51: 1276–8. doi: 10.1016/j.jvs.2009.12.049
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5.
6.
7.
8.
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