J. Coloproctol. (Rio J.) vol.35 número1

jcoloproctol(rioj).2015;35(1):59–62

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Case

Report

Appendicitis

caused

by

ingestion

of

metal

foreign

body

José

Inácio

de

Almeida

Neto

,

Bruna

Schawn

Guerini

,

Felipe

Fernandes

Nogueira

de

Almeida

a_{GeneralSurgeryService,HospitaldeClínicasDr.RadamésNardini,Mauá,SP,Brazil} b_{HospitaldeClínicasDr.RadamésNardini,Mauá,SP,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received13December2013 Accepted11August2014 Availableonline28January2015

Keywords:

Appendicitis

Foreign-bodymigration Appendix

Laparotomy

a

b

s

t

r

a

c

t

Introduction:Theingestionofforeignbodiesisafrequentoccurrence,especiallyamong chil-dren.Themajorityoftheseobjectstravelsafelythroughthegastrointestinaltract,without causingsymptomsorleavingsequelae.Acuteappendicitisistheemergencysurgical pathol-ogyofgreaterprevalence.However,theimpactionofaforeignbodyintotheappendicular lumenasanetiologicagentofappendicitisisaveryrareevent.

Casereport:Wedescribethecaseofa21-year-oldmalepatientwithlowerabdominalpain overapproximatelysixdays,inassociationwithvomiting,feverandabdominaldistension. Afterimagingstudies,aradiopaqueforeignbodywasidentifiedinapelvictopography,with distentionandair-fluidlevelsinintestinalloops.Ourpatientwassubmittedtoanopen appendectomy,evidencingacuteperforatedappendicitisandthepresenceoftwoforeign bodiesinitslumen.Thepatientprogressedsatisfactorilyinthepost-operativeperiod,with useofbroad-spectrumantibiotics.

Discussion: Foreignbodiesimpactedinthegastrointestinal tractareusuallyremovedby endoscopictechniques.Whenthesebodiescauseinfections,thereshouldbearesolution, preferablybysurgicallaparoscopy,whichwillservebothfordiagnosticastherapeutic pur-poses.

©2015SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.

Apendicite

provocada

por

ingesta

de

corpos

estranhos

metálicos

Palavras-chave:

Apendicite

Corpoestranho,migrac¸ão Apêndice

Laparotomia

r

e

s

u

m

o

Introduc¸ão: Aingestadecorposestranhoséumacontecimentofrequente,principalmente entrecrianc¸as.Amaioriadestespassadeformainócuapelo tratogastrointestinal,sem causarsintomasoudeixarsequelas.Apendiciteagudaéapatologiacirúrgicaemergencial demaiorprevalência.

∗ _{Correspondingauthor.}

E-mail:jialmeidacirplast@gmail.com(J.I.deAlmeidaNeto). http://dx.doi.org/10.1016/j.jcol.2014.08.014

60

Contudo:aimpactac¸ãodeumcorpoestranhonolúmenapendicularcomoagenteetiológico deapendiciteéumeventomuitoraro.

Relatodecaso:Descrevemosocasodeumpacientemasculinode21anoscomquadrodedor abdominalbaixaháaproximadamente6dias,associando-seavômitos,febreedistensão abdominal.Apósexamesdeimagem,identificou-secorpoestranhoradiopacoemtopografia pélvica,distensãoeníveishidroaéreosemalc¸asintestinais.Foisubmetidoa apendicecto-mialaparotômica,evidenciando-seapendiciteagudaperfuradaepresenc¸adedoiscorpos estranhosemseulúmen.Evoluiudeformasatisfatórianopós-operatório,tendo-sefeito usodeantibióticosdelargoespectro.

Discussão: Corposestranhosimpactadosnotratogastrointestinalsãousualmenteretirados portécnicasendoscópicas.Quandoprovocamquadrosinfecciosos,deve-seprocederauma resoluc¸ãocirúrgica,preferencialmenteporvideolaparoscopia,aqualservirátantoparafins diagnósticosquantoterapêuticos.

©2015SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.

Introduction

Appendectomyisthemostcommonemergencysurgical pro-cedure worldwide.1 _{However, these procedures remove up}

to28.7% ofnormalappendices,evenwith theevolution of diagnosticmethods.Thispercentageisevenhigherinyoung women.1,2

Theingestionofinedibleandindigestibleobjectsisvery common,especially in younger age groups. In adults, this occursaccidentally,orinpatientswithmentalretardation.3

Thepresenceofaforeignbodyintheappendix,actingasa causeofaninflammatoryprocess,isaveryrareevent.4

Wedescribeacaseofacuteappendicitiscausedby inges-tionofametalobject,whichimpactedintotheappendiceal lumen, comparing the conduct taken witha reviewofthe existingliteratureonthesubject.

Case

report

Amale patient, 21 years old,was admittedto the general surgeryemergencydepartment witha24-h non-irradiating abdominalpainontherightiliacfossa(RIF),without aggra-vatingor mitigatingfactors, and associated with vomiting episodes.Thepatienthadnoothercomplaintsrelatedtothe gastrointestinaltractandwithnohistoryofcommorbidities, surgeryorallergies.Thephysicalexaminationrevealedpain onpalpationofRIF,butwithoutsignsofperitonealirritation; air-fluidsoundspresent,withnopalpablemasses.Thepatient hadmildleukocytosis(12,600leukocytes),withoutpresenceof rods.Anabdominalultrasoundwasperformed,which identi-fiedtwometallicforeignbodieslocatedinthepelvisorright iliacfossa.

A CT scan of the pelvis confirmed the presence of radiopaquebodies;wecouldnotdeterminewhethertheywere locatedintheinteriorofthegastrointestinaltractorinthe abdominalcavity(Fig.1).Thepatienthadhispainsymptoms improved,withnormalbowelmovementsduringthefirst48h afteradmission,whenfledthehospitalafter72h.

Fig.1–Computedtomography.

Thepatient returnedwithworsening ofpainsymptoms after48hofevasion,nowwiththeadditionofbowel bloat-ingandmultipleemeticepisodes,withperitonealirritationon physicalexamination.Anewradiographyrevealedagainthe pelvicforeign bodies,plusair-fluidlevelsinsmallintestine topography(Fig.2).

Surgery wasindicatedand performedbyan exploratory laparotomy,whenanacuteappendicitiswasidentified,with necrosisandperforationofthevermiformappendixand pres-enceoftwometalbodiesintoitslumen(Figs.3and4);Thus, aconventionalappendectomywasperformed.

jcoloproctol(rioj).2015;35(1):59–62

61

Fig.2– Radiographyoftheabdomen.

Fig.3–Vermiformappendix.

Fig.4–Appendixandforeignbodies.

wasdischargedonthe5thpostoperativeday,withacceptance ofageneraldietandwithnormalbowelhabits.

Discussion

Theingestionofforeign bodiesisacommon phenomenon inclinicalpractice,especiallyamongchildrenandinadults withmentalretardation;2_{inmostcases,thesearefragments}

offishorpoultrybone,dentalprosthesesorleadfragments (present in slaughtered poultry products).In general, their passagethroughthegastrointestinaltractisasymptomatic,5

andthepresenceofcomplicationssuchasintestinal perfora-tion,abscessorbowelobstructionbeingarareevent.3,6_The

impactionofforeign bodiesinto theappendixisan excep-tionalevent;acuteappendicitiscausedbyaforeignbodyhas aprevalenceof0.0005%,2,5_{andthelatencytimebetweenthe}

ingestion of the foreign body and the onset of symptoms couldbemeasuredinyears.7_{Inourcase,thepatientdoesnot}

62

Thereisstillcontroversyabouttheactiontobetakenafter theingestionofanasymptomaticforeignbody.Klingeretal. proposetheendoscopicremovalofallforeignbodiesbyupper gastrointestinalendoscopy;ifthisprocedureisnotavailable, thecaseshouldbeaccompaniedwithserialradiographsand leucograms.8

Colonoscopyshouldbeusedtoremovestationaryobjects inthelowerrightquadrantoftheabdomenforaperiodofat least72h,eveniftheseobjectsareasymptomatic.8,9

In fact, thin and pointed impacted objects show a greaterpropensitytocausesymptoms,around93%ofcases; abscesses(88%)orintestinalperforation(70%)are themost commonfindings.Ontheotherhand,bluntobjects maybe asymptomaticforlongperiods,andanincidenceofupto66% ofappendicitisinthecaseofimpactionofsuchobjectswas reported.3

If the endoscopic removal failed, a fluoroscopy-guided laparoscopytoremovetheseforeignbodiesisindicated.2

Thepositioningofthe appendix inamorecaudal loca-tionthantheusualmaybeduetotheweightcausedbythe presenceofbothforeignbodiesintothelumen;inaway,this complicatestheexactlocationoftheseobjects.

Inthe casein study,the endoscopicprocedure was not attempted,sincetherewas asurgicalindicationduetothe inflammationcausedbytheforeignbodies.Failuretouse a laparoscopicprocedurewasduetotheunavailabilityofthis procedureintheperiodwhenthepatientwasseen.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

r

e

f

e

r

e

n

c

e

s

1.ChandrasegaramMD,RothwellLA,AnEI,MillerRJ.Pathologies oftheappendix:a10-yearreviewof4670appendicectomy specimens.ANZJSurg.2012;82:844–7.

2.KlinglerPJ,SeeligMH,DeVaultKR,WetscherGJ,FlochNR, BrantonSA,etal.Ingestedforeignbodieswithintheappendix: a100-yearreviewoftheliterature.DigDis.1998;16:308–14. 3.BenizriEI,CohenC,BerederJM,RahiliA,BenchimolD.

Swallowingasafetypin:reportofacase.WorldJGastrointest Surg.2012;4:20–2.

4.BaekSK,BaeOS,HwangI.Perforatedappendicitiscausedby foreignbodyingestion.SurgLaparoscEndoscPercutanTech. 2012;22:e94–7.

5.SarS,MahawarKK,MarshR,SmallPK.Recurrentappendicitis followingsuccessfulconservativemanagementofan appendicularmassinassociationwithaforeignbody:acase report.CasesJ.2009;2:7776.

6.PilichosC,TasiasG,PylerisE,AnyfantisN,PantelarosN, BarbatzasC.Endoscopicextractionofametalkeyimpacted withintheappendix.WorldJGastrointestEndosc.2010;2: 372–4.

7.SelfaMunozA,PalaciosPerezA,MartinezTiradoP,Barrientos DelgadoA.Anunusualcauseofacuteappendicitis.MedClin. 2012;138:e15.

8.SarkarRR,BishtJ,SinhaRoySK.Ingestedmetallicforeignbody lodgedintheappendix.JIndianAssocPediatrSurg.

2011;16:29–30.