Ingestion of FBs is a fairly common event and is not usually related to any untoward effect, as the majority of objects pass uneventfully through the gastrointestinal tract.5 6
Ingested FBs can get impacted at any point in the gastrointestinal tract from the oesophagus to the anus, typically at areas of physiologic narrowing or acute angulation of the intestine such as the upper and lower oesophageal sphincters, pylorus, duodenal sweep, ileo-caecal valve and anal area. The most common areas of perforation are the ileum, appendix and colon.7
Our patient's perforation was most likely preceded by impaction of the CS at the jejunum approximately halfway between the duodeno-jejunal flexure and ileo-caecal valve. The clinical presentation was subtle because the perforation was not free, but the small bowel mesentery was enwrapping it. The site and the overall manifestation of the perforation did not correlate with the findings in previous reports.
Several factors have been reported as predisposing to the accidental swallowing of FBs. These include rapid bolting of food, carelessness, alcohol intoxication, habit of chewing on FBs and decreased sensitivity of the palatal surface (eg, due to the use of dentures).8
Most individuals who ingest FBs are unaware of swallowing them.5
In a review of the literature Li and Ender reported that only 12% of patients remembered swallowing a TP and just 21% recalled eating something with a TP without swallowing the TP.4
In patients who remember swallowing a TP, the maximum reported interval between the ingestion and presentation with related symptoms was 15 years. In our patient's case, it was probably the rapid bolting of food and carelessness that caused him to unintentionally swallow a CS. He recalled eating quickly a club sandwich embedded with a few CSs 3 days prior to the initiation of the symptoms. On admission he reported a 10-year history of periodic upper abdominal pain associated with nausea and complete constipation but with spontaneous resolution. Although it is highly unlikely that these episodes are related to the recently diagnosed perforation, the possibility of an unremembered episode of accidental swallowing of a CS 10 years prior to admission could not be excluded.
All the abovementioned factors suggest that an ingested FB injury may not be suspected in a patient who presents with longstanding unexplained symptoms. This difficulty in diagnosis is compounded by the fact that there is usually a wide spectrum of clinical conditions which would more readily be considered.3
Furthermore, plain radiology is inadequate in detecting radiolucent FBs such as CSs, which are usually made of wood or plastic. In a recent literature review it was reported that TPs were apparent on imaging studies in only 14% of the cases with detection sensitivities of less than 30% for both CT and ultrasound scans.4
It was further stated that most TP injuries are diagnosed at exploratory surgery, most commonly laparotomy. In our patient's case, ultrasonography failed to demonstrate the CS, and even CT scan showed an abnormal area with surrounding inflammation, which was by no means diagnostic.
Ingested CS injuries are often associated with considerable morbidity and mortality. Schwartz and Graham9
observed two deaths out of their five reported cases, and Li and Ender4
literature review revealed mortality of 18%. This is contributed to the diagnostic elusiveness of TP perforation, mainly because patients rarely relate a history of swallowing TPs.9
Therefore, impacted or perforated sharp FB should be in the differential diagnosis in any abdominal pain presentation of unclear aetiology.10
Careful questioning about eating habit and food intake is an essential element of the history in undiagnosed acute abdomen. To an extent, an early suspected diagnosis can effectively prevent a fatal outcome. The physical examination is then the best indicator of an injury.4
The persistence of clinical signs in our case led us to suspect an injury. That was picked up and dealt with by exploratory surgery with no immediate and short-term morbidity.
In retrospect and because of the location of CS injury in our case, the overall management would not have been altered even if we were to consider other diagnostic methods. Endoscopic diagnosis and extraction of the CS has been reported previously.10
Yet the usage of capsular endoscopy, which was never been reported in the past, could have only played a role and possibly delayed the diagnosis.
- An ingested CS can cause serious damage to the gastrointestinal tract. Complications such as perforation occur subsequent to impaction and the diagnosis is usually challenging.
- Most patients do not recall the swallowing event and usually the imaging techniques are not adequate.
- High index of suspicion is required and careful history taking is usually the mainstay for provisional diagnosis.
- As most reported cases in the literature have proven to date, an exploratory laparotomy is usually required to diagnose as well as to treat the patient.