Small bowel obstruction is a frequent cause of emergency surgery. Causes of small bowel obstruction are adhesion (60%), hernia (15%), neoplasm (6%), inflammatory (5%), and sometimes ingested foreign body, but rarely food bolus [1
Patients with ingested foreign body are commonly children, elderly with dental prosthesis, alcoholic, prisoner inmates, and psychiatric patients [1
]. Our patient did not fit into any of these categories. Coins, small toys, pins, and alkaline button batteries are some of the commonly ingested foreign bodies. Most of the ingested foreign bodies pass through the entire gastrointestinal tract without causing any complications, but if they are impacted in the gastro intestinal tract then they can cause obstruction, perforation, or fistula formation [1
Food bolus impaction is common with meat, fish bones, and very few cases due to fruits have been reported [4
]. It is seen in old people with poor natural teeth or ill-fitting dentures, or inadequate mastication as in our case [3
]. Food bolus can get impacted at sites of narrowing in the gastro intestinal tract like cricopharyngeal sphincter, constriction in oesophagus (due to arch of aorta and bronchus), distal ileum (2 feet proximal to ileocaecal junction), ileocaecal junction and any pathological stricture in small bowel. Ingested foreign body longer than 6 cm is likely to be impacted in the second or third part of duodenum; however, rounded foreign bodies larger than 2.5 cm in diameter are less likely to pass beyond pylorus itself [2
]. Presenting symptoms vary depending on site of impaction, type of ingested food, and presence or absence of complications. If food particle is impacted in oesophagus, then symptoms range from foreign body sensation, chest pain, odynophagia, vomiting, and respiratory symptoms.
Patients with impaction in small intestine present with symptoms of vomiting, abdominal distension, and constipation. There are cases of cholangitis [5
] and recurrent pancreatitis [6
] caused by food bolus impacted at papilla of Vater.
Sharp foreign bodies can perforate and present with mediastinitis or perforative peritonitis depending on site of perforation. Majority of the foreign bodies pass spontaneously and only 1% or less will require surgery [2
Radiological investigations have limitations in studying bowel obstruction from foreign bodies, especially if when they are not radio-opaque. Plain abdominal film has sensitivity of 86% to diagnose high-grade bowel obstruction and will show air fluid level with dilated loops of small bowel [3
]. An intramural width of small intestine of 3 cm is considered abnormal. Ultrasound may clearly demonstrate loops of distended small bowel with hyper peristalsis. Occasionally, the foreign body may be identified on ultrasound as an echogenic intraluminal mass and may cast an acoustic shadow if surrounded by fluid. When above investigations are inconclusive an abdominal CT scan is of great help in the diagnosis and detecting aetiology in 73–95% of cases [3
Most ingested foreign bodies that have passed pylorus pass through rest of the gastro-intestinal tract, within a mean of 4 days. Ingested blunt foreign body distal to stomach are monitored by weekly abdominal X-rays, and daily X-rays in case of sharp objects. Intervention is required if the blunt foreign body remains in same place for more than a week, and sharp object remains in same place for more than 3 days [2
Foreign bodies in oesophagus or stomach can be successfully removed endoscopically. Urgent endoscopic intervention is required in case of sharp objects, disk battery or if there is risk of aspiration. Under no circumstances should a foreign object or food bolus impaction be allowed to remain in the oesophagus beyond 24 hours from presentation [2
]. Patients in whom endoscopic retrieval has failed are often referred for surgical extraction. Foreign body impacted in small bowel can be removed by open or laparoscopic methods. Proximal bowel should be checked for any other ingested foreign body. Careful examination of bowel at the site of impaction should be done to rule out a pathological stricture.
Early diagnosis and therapeutic management has considerable importance. Obstruction of the bowel due to impacted food bolus is difficult to diagnose preoperatively unless there is clear history and the diagnosis is usually made intraoperatively [4
]. Generally, laparotomy is performed for diagnosis and management in such cases, but with increasing expertise, laparoscopy can be equally effective with all the other advantages of minimal access approach [9
]. We recommend this approach for removal of ingested foreign body impacted in small intestine. The only disadvantage could be inability to feel the dilated bowel and conclusively rule out any other foreign body in proximal segment.