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J R Soc Med. 2004 May; 97(5): 241–242.
PMCID: PMC1079467

Gastric ligneoma

P A Whitehouse, MRCS
Department of Surgery, Crawley Hospital, Crawley, West Sussex RH11 7DH
G P Gartell, MS FRCS1

Most ingested foreign bodies pass through the gastrointestinal tract uneventfully. However, sharp objects have the potential to cause intestinal perforation and other severe complications, even death.

CASE HISTORY

A woman aged 57 was admitted as an emergency with colicky left-sided abdominal pain which had been present intermittently for eighteen months. She reported considerable weight loss despite a good appetite with no change in bowel habit. Clinically she was cachectic and pyrexial with no anaemia or jaundice. She had left iliac fossa tenderness with guarding and rebound tenderness, and a large mass was palpable in the left upper quadrant. Blood indices were normal apart from a raised white cell count (20.3×109/L), alkaline phosphatase (457 IU/L) and C-reactive protein (145 mg/L). Tumour markers were normal and plain abdominal X-ray was unremarkable. CT scan showed a well circumscribed 5 cm mass in the body of the stomach that enhanced peripherally but not centrally (Figure 1). No metastatic liver lesions or lymph nodes were identified. Upper gastrointestinal endoscopy revealed a small sliding hiatus hernia and a 15 mm chronic gastric ulcer in the antrum with no other mucosal abnormalities. The clinical and radiological diagnosis was a stromal tumour.

Figure 1
CT showing mass in the body of the stomach enhancing peripherally but not centrally

At laparotomy the mass appeared to be infiltrating the pancreas, with no intraperitoneal tumour deposits or liver metastases. A partial gastrectomy was performed together with removal of a cuff of tissue where it was infiltrating lesser sac structures. Postoperatively she developed a 9.5 cm pseudocyst that was drained percutaneously, and subsequently a large volume pancreatic leak from the wound with severe skin excoriation. She was discharged home on Creon (pancreatin) for steatorrhoea, after two months in hospital including stays in intensive care and high dependency beds. For eighteen months a small pseudocyst remained but was treated conservatively and eventually settled.

The histopathological diagnosis was an intramural abscess and inflammatory mass with foreign body granulomata surrounding a 4.2 cm cocktail stick (Figure 2). There was no evidence of neoplasia. The patient had no recollection of ever swallowing a cocktail stick.

Figure 2
Specimen of resected stomach showing inflammatory mass surrounding cocktail stick

COMMENT

Once past the oesophagus, most ingested foreign bodies pass through the gastrointestinal tract without any adverse sequelae. However, long sharp objects have the potential to cause intestinal perforation, abscesses or bleeding and may even result in death.1 In the present case the composition of the object made it invisible to usual imaging.

There are several published cases of intestinal perforation by sharp ingested objects, which may penetrate into surrounding structures including the vena cava.2 Perforation may be symptomless and the offending item found on radiological investigation or at laparotomy for other reasons.3

Reduced palatal sensation from wearing dentures, the consumption of very hot or cold drinks, excess alcohol and rapid eating are all associated with the ingestion of foreign bodies in adults, as is the habitual ‘chewing’ of toothpicks.2 Endoscopic management is preferable to laparotomy if the diagnosis is made at the time of ingestion and should be performed early to prevent perforation or bleeding. Delay in diagnosis may result in an inflammatory mass or diffuse peritonitis.4

References

1. Kasthuri N, Savage A. Cocktail stick injury: a fatal outcome. BMJ (Clin Res Ed) 1988;296: 498 [PMC free article] [PubMed]
2. Cockerill FR, 3rd, Wilson WR, Van Scoy RE. Travelling toothpicks. Mayo Clin Proc 1983;58: 613-16 [PubMed]
3. Porcu A, Dessanti A, Feo CF, Dettori G. Asymptomatic perforation by a toothpick. Dig Surg 1999;16: 437-8 [PubMed]
4. Mohr HH, Dierkes-Globisch A. Endoscopic removal of a perforating toothpick. Endoscopy 2001;33: 295. [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press