- Email: [email protected]
Fractured rib as a foreign body of the colon
Brief Reports 9. Lamont JP, Hooker G, Espenschied JR, et al. Closure of proximal colorectal fistulas using fibrin sealant. Am Surg 2002;68:615-8. 10. Samalin E, Audin H, Senesse P. Endoscopic treatment of oesophageal fistulae with glue injections (cyanoacrylate, Histoacryl). Gastroenterol Clin Biol 2005;29:612-3. 11. Lee YC, Na HG, Suh JH, et al. Three cases of fistulae arising from gastrointestinal tract treated with endoscopic injection of Histoacryl. Endoscopy 2001;33:184-6. 12. Dalton D, Woods S. Successful endoscopic treatment of enterocutaneous fistulas by Histoacryl glue. Aust N Z J Surg 2000;70:749-50. 13. Cipolletta L, Bianco MA, Rotondano G, et al. Endoscopic clipping of perforation following pneumatic dilation of esophagojejunal anastomotic strictures. Endoscopy 2000;32:720-2.
Received April 6, 2007. Accepted May 14, 2007. Current affiliations: Division of Gastroenterology (G.R., L.O., F.C., M.A.B., M.L.G., L.C.), Hospital ‘‘A. Maresca,’’ Torre del Greco, Section of Gastrointestinal Endoscopy (G.R., M.V.), Division of Surgery, Civil Hospital, Roccadaspide, Italy. Reprint requests: Gianluca Rotondano, MD, Gastroenterology, Hospital Maresca, Torre del Greco, Via Cappella Vecchia 8, 80121 Naples, Italy. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.05.025
Fractured rib as a foreign body of the colon Muharem Zildzic, PhD, Nermin Salkic, MSc, Izet Eminovic, PhD, Deso Mesic, PhD Tuzla, Bosnia and Herzegovina
There are numerous reports about foreign bodies in any part of the GI tract and about various therapeutic modalities that deal with their removal.1,2 However, a foreign body that does not enter the GI tract through the mouth or rectum is a clinical curiosity, and reports about those cases are rare.3 This is the first reported case of a fractured rib fragment penetrating the intestinal wall, impacting in the lumen and remaining there for several years without any signs of serious illness in the patient.
CASE REPORT A 49-year-old man was admitted to the hospital for a single complaint of prolonged mild pain in the lower left quadrant of the abdomen that had started 6 months before. On physical examination, we found mild tenderness in the left lower quadrant of the abdomen and a small linear surface scar in the left lumbar region. The patient reported that it was a remainder of a shallow cut wound that he had gotten 9 years before after a contusion of the left side of the thorax and abdomen from a blast injury during the Bosnian war of 1992-1995. At the time he did not have any other visible injuries and, because of war conditions, was not examined by a physician. The cut wound healed spontaneously. The general physical status of the patient was excellent and all labortory tests were within reference values. On admission an abdominal US was performed, which revealed wall thickening of the descending colon with a strong echo in the form of a plate in the lumen measuring 40 20 mm (Fig. 1A). Abdominal CT confirmed stenosis of the descending colon with an impacted foreign body of high density very suspicious to actually be a bone. Although there were no
apparent sites of possible fracture, the tip of the 9th rib on the left side had a somewhat irregular appearance (Figs. 1B and C). On colonoscopy the impacted foreign body was encountered at 50 cm. The surrounding wall showed signs of inflammation with reactive proliferation and edema. The lumen was almost completely obstructed, and further intubation was impossible (Fig. 2A). Endoscopic extraction was unsuccessful because of deep impaction and a clear danger from perforation.
186 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 1 : 2008
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Figure 1. A, US of descending colon: foreign body in intestinal lumen. B and C, CT scan: visible foreign body in intestinal lumen. Note irregular tip of 9th rib on CT scan survey (B, upper arrow).
Brief Reports
Figure 2. A, Colonoscopy: impacted foreign body at the descending colon level (marked with line) with extreme wall edema and lumen narrowing (arrow points at stenotic lumen). B, Foreign body extracted from intestinal lumen after surgical resection.
tured tip of the rib penetrating the colon and impacting there.
DISCUSSION
After we presented our findings to the patient and expressed the possibility that it might be ingested, the patient insisted that he never swallowed anything of that size. He was then referred to surgery, which was successful with extraction of a foreign body measuring 45 23 mm and resembling a piece of rib (Fig. 2B). The bone fragment and the patient’s blood were sent for a DNA analysis, which confirmed that they were from the same person, thus confirming the theory of frac-
As an example of a foreign body entering the GI tract through its wall, gunshot wounding in the left lumbar area has been described, with penetration of the bullet into the colon and its spontaneous elimination through the rectum without any signs of peritonitis, sepsis, or fistula.3 Intestinal injuries caused by small-velocity projectiles having little or no cavitation effect on the surrounding tissues may spontaneously heal without any major leak of intestinal juices into the peritoneal cavity.4 Minimal colonic perforations, such as those induced by barotraumas during colonoscopy, might be successfully treated conservatively.5 An important factor we have to consider is that soldiers during the Bosnian war were provided with infrequent
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Volume 67, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 187
Figure 1 (continued)
Brief Reports
meals consisting of low-residue ingredients, probably resulting in smaller amount of intestinal juices at the moment of penetration and thus reducing any consequent leakage into the peritoneal cavity. It is possible that the rib fragment partially penetrated the colonic wall, acting as a plug that would keep intestinal juices from leaking. Reparative processes after penetration might have produced enough scar tissue to grow over the rib fragment, trapping it impacted in the colon. The fact that the rib fragment was the patient’s own tissue could facilitate such a process. However, at this time, it is impossible to determine the true course of events. DISCLOSURE The authors report that there are no disclosures relevant to this publication.
2. Chaves DM, Ishioka S, Felix VN, et al. Removal of a foreign body from the upper gastrointestinal tract with a flexible endoscope: a prospective study. Endoscopy 2004;36:887-92. 3. Navsaria P, Nicol A. Spontaneous expulsion of an intracolonic missile after penetrating trauma: a case report. J Trauma 2002;53: 586-7. 4. Swan KG, Swan RC. Principles of ballistics applicable to treatment of gunshot wounds. Surg Clin North Am 1991;71:221-39. 5. Makharia GK, Madan K, Garg PK, et al. Colonoscopic barotrauma treated by conservative management: role of high-flow oxygen inhalation. Endoscopy 2002;34:1010-3.
Department of Gastroenterology, Internal Medicine Hospital (M.Z., N.S.) and Surgery Hospital (D.M.), University Clinical Center, Department of Biomedical Engineering, Tuzla University School of Medicine (I.E.), Tuzla, Bosnia and Herzegovina. Presented in part without DNA analysis in form of poster at 2nd Congress of Gastroenterologists of Bosnia and Herzegovina, September 2006. Reprint requests: Nermin Salkic, MD, MSc, Miroslava Krleze 15/26, 75000 Tuzla, Bosnia and Herzegovina.
REFERENCES
Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00
1. Kim JK, Kim SS, Kim JI, et al. Management of foreign bodies in the gastrointestinal tract: an analysis of 104 cases in children. Endoscopy 1999;31:302-4.
doi:10.1016/j.gie.2007.05.018
188 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 1 : 2008
www.giejournal.org
Received April 6, 2007. Accepted May 14, 2007. Current affiliations: Division of Gastroenterology (G.R., L.O., F.C., M.A.B., M.L.G., L.C.), Hospital ‘‘A. Maresca,’’ Torre del Greco, Section of Gastrointestinal Endoscopy (G.R., M.V.), Division of Surgery, Civil Hospital, Roccadaspide, Italy. Reprint requests: Gianluca Rotondano, MD, Gastroenterology, Hospital Maresca, Torre del Greco, Via Cappella Vecchia 8, 80121 Naples, Italy. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.05.025
Fractured rib as a foreign body of the colon Muharem Zildzic, PhD, Nermin Salkic, MSc, Izet Eminovic, PhD, Deso Mesic, PhD Tuzla, Bosnia and Herzegovina
There are numerous reports about foreign bodies in any part of the GI tract and about various therapeutic modalities that deal with their removal.1,2 However, a foreign body that does not enter the GI tract through the mouth or rectum is a clinical curiosity, and reports about those cases are rare.3 This is the first reported case of a fractured rib fragment penetrating the intestinal wall, impacting in the lumen and remaining there for several years without any signs of serious illness in the patient.
CASE REPORT A 49-year-old man was admitted to the hospital for a single complaint of prolonged mild pain in the lower left quadrant of the abdomen that had started 6 months before. On physical examination, we found mild tenderness in the left lower quadrant of the abdomen and a small linear surface scar in the left lumbar region. The patient reported that it was a remainder of a shallow cut wound that he had gotten 9 years before after a contusion of the left side of the thorax and abdomen from a blast injury during the Bosnian war of 1992-1995. At the time he did not have any other visible injuries and, because of war conditions, was not examined by a physician. The cut wound healed spontaneously. The general physical status of the patient was excellent and all labortory tests were within reference values. On admission an abdominal US was performed, which revealed wall thickening of the descending colon with a strong echo in the form of a plate in the lumen measuring 40 20 mm (Fig. 1A). Abdominal CT confirmed stenosis of the descending colon with an impacted foreign body of high density very suspicious to actually be a bone. Although there were no
apparent sites of possible fracture, the tip of the 9th rib on the left side had a somewhat irregular appearance (Figs. 1B and C). On colonoscopy the impacted foreign body was encountered at 50 cm. The surrounding wall showed signs of inflammation with reactive proliferation and edema. The lumen was almost completely obstructed, and further intubation was impossible (Fig. 2A). Endoscopic extraction was unsuccessful because of deep impaction and a clear danger from perforation.
186 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 1 : 2008
www.giejournal.org
Figure 1. A, US of descending colon: foreign body in intestinal lumen. B and C, CT scan: visible foreign body in intestinal lumen. Note irregular tip of 9th rib on CT scan survey (B, upper arrow).
Brief Reports
Figure 2. A, Colonoscopy: impacted foreign body at the descending colon level (marked with line) with extreme wall edema and lumen narrowing (arrow points at stenotic lumen). B, Foreign body extracted from intestinal lumen after surgical resection.
tured tip of the rib penetrating the colon and impacting there.
DISCUSSION
After we presented our findings to the patient and expressed the possibility that it might be ingested, the patient insisted that he never swallowed anything of that size. He was then referred to surgery, which was successful with extraction of a foreign body measuring 45 23 mm and resembling a piece of rib (Fig. 2B). The bone fragment and the patient’s blood were sent for a DNA analysis, which confirmed that they were from the same person, thus confirming the theory of frac-
As an example of a foreign body entering the GI tract through its wall, gunshot wounding in the left lumbar area has been described, with penetration of the bullet into the colon and its spontaneous elimination through the rectum without any signs of peritonitis, sepsis, or fistula.3 Intestinal injuries caused by small-velocity projectiles having little or no cavitation effect on the surrounding tissues may spontaneously heal without any major leak of intestinal juices into the peritoneal cavity.4 Minimal colonic perforations, such as those induced by barotraumas during colonoscopy, might be successfully treated conservatively.5 An important factor we have to consider is that soldiers during the Bosnian war were provided with infrequent
www.giejournal.org
Volume 67, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 187
Figure 1 (continued)
Brief Reports
meals consisting of low-residue ingredients, probably resulting in smaller amount of intestinal juices at the moment of penetration and thus reducing any consequent leakage into the peritoneal cavity. It is possible that the rib fragment partially penetrated the colonic wall, acting as a plug that would keep intestinal juices from leaking. Reparative processes after penetration might have produced enough scar tissue to grow over the rib fragment, trapping it impacted in the colon. The fact that the rib fragment was the patient’s own tissue could facilitate such a process. However, at this time, it is impossible to determine the true course of events. DISCLOSURE The authors report that there are no disclosures relevant to this publication.
2. Chaves DM, Ishioka S, Felix VN, et al. Removal of a foreign body from the upper gastrointestinal tract with a flexible endoscope: a prospective study. Endoscopy 2004;36:887-92. 3. Navsaria P, Nicol A. Spontaneous expulsion of an intracolonic missile after penetrating trauma: a case report. J Trauma 2002;53: 586-7. 4. Swan KG, Swan RC. Principles of ballistics applicable to treatment of gunshot wounds. Surg Clin North Am 1991;71:221-39. 5. Makharia GK, Madan K, Garg PK, et al. Colonoscopic barotrauma treated by conservative management: role of high-flow oxygen inhalation. Endoscopy 2002;34:1010-3.
Department of Gastroenterology, Internal Medicine Hospital (M.Z., N.S.) and Surgery Hospital (D.M.), University Clinical Center, Department of Biomedical Engineering, Tuzla University School of Medicine (I.E.), Tuzla, Bosnia and Herzegovina. Presented in part without DNA analysis in form of poster at 2nd Congress of Gastroenterologists of Bosnia and Herzegovina, September 2006. Reprint requests: Nermin Salkic, MD, MSc, Miroslava Krleze 15/26, 75000 Tuzla, Bosnia and Herzegovina.
REFERENCES
Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00
1. Kim JK, Kim SS, Kim JI, et al. Management of foreign bodies in the gastrointestinal tract: an analysis of 104 cases in children. Endoscopy 1999;31:302-4.
doi:10.1016/j.gie.2007.05.018
188 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 1 : 2008
www.giejournal.org