- Email: [email protected]
Chronic Perforation of the Sigmoid Colon by Foreign Body
ORIGINAL REPORTS
Chronic Perforation of the Sigmoid Colon by Foreign Body Fawzi E. Ali, MS,* Waleed A. Al-Busairi, MD,* Emad Y. Esbaita, MS,* and Mahmoud A. Al-Bustan, HSD† *Medical Rehabilitation Center, Kuwait, and †Faculty of Medicine, Kuwait University, Kuwait Colorectal foreign bodies (FBs) may be ingested or introduced transanally and then migrate proximally. Without a reliable history, it may be impossible to determine which way a certain colorectal FB gained access. We present a case of a nonverbal mentally retarded boy with a flat piece of plastic impacted in the sigmoid colon, the colonoscopic extraction of which failed. He underwent laparotomy more than a year later to remove the FB, where chronic perforation of the sigmoid colon was discovered. The perforation was sealed with extensive adhesions to the pelvic wall, and histologically, the colon showed a chronic granulomatous reaction. We discuss the types, presentations, and diagnosis of intestinal perforation with FBs. Chronic perforation may present with radiologic and pathologic features that suggest inflammatory bowel disease. (Curr Surg 62:419-422. © 2005 by the Association of Program Directors in Surgery.)
Absent an accurate medical history, it may be impossible for a physician to determine if a certain colorectal FB was ingested or passed per anum. Most people who accidentally ingest FBs are unaware of the incident,3,7 and most people who insert FBs per anum give misleading history to avoid social embarrassment.1,6 Mentally ill patients may give an unreliable history, and mentally retarded subjects may be too cognitively impaired to give a history. The nature of the FB can be helpful in deciding which way it entered the body as chicken bones, tooth picks, and dental prostheses are obviously ingested. Sex toys such as dildos and vibrators are obviously inserted transanally. Colorectal FBs, which by their sheer size and shape, could not have traversed the upper gastrointestinal tract (eg, bottles and jars) must have been passed up through the anus.
KEY WORDS: foreign body, intestinal perforation, mental
CASE REPORT
retardation, sigmoid colon
INTRODUCTION Colorectal foreign bodies (FBs) may be ingested or introduced by the anal route.1 Although most ingested FBs traverse the length of the gastrointestinal tract and exit naturally, complications such as impaction, obstruction, perforation, and hemorrhage occasionally occur.2,3 The most common sites for narrowing and impaction are the upper and lower esophageal sphincters, the pylorus, and the ileocecal valve.1 Still, some FBs can negotiate these hurdles and get impacted lower down in the colon, rectum, and anal canal.4 Foreign body ingestion in adults is associated with denture-wearing in elderly people, alcohol and drug abuse, incarceration, mental retardation, and mental illness.1 On the other hand, FBs introduced transanally can migrate proximally up to the hepatic flexure.5 Such FBs are mostly inserted by the patient or a partner for sexual stimulation, but other causes include relief of anorectal conditions, sexual assault, medical instrumentation, accidental introduction, and psychiatric illness.1,6 Correspondence: Inquiries to Fawzi E. Ali, MS, P.O. Box 1240 Surra, Code 45713, Kuwait; fax: (965) 4875409; e-mail: [email protected]
A 16-year-old Kuwaiti boy presented with an episode of bleeding per rectum lasting for 2 hours. He was severely retarded and nonverbal. He had been institutionalized since the age of 8 years at a state-run residential facility in Kuwait. There was no history of gastrointestinal disease or abdominal surgery. He took no medications. Abdominal examination was normal, and rectal examination failed to find a source for the bleeding. The laboratory data were significant only for polymorph leukocytosis (Total white blood cell count 20 ⫻ 109/l) and a moderate degree of normocytic normochromic anemia (red blood cell count 3.75 ⫻ 1012/l, Hgb 11.5 g/dl, and Hct 33.4%). Ultrasound scan of the abdomen was unremarkable. At colonoscopy, no source of bleeding was observed up to the midsigmoid, where a yellow-colored plastic FB was found adjoining an injury-induced ulcer (Fig. 1). The FB was lodged in position, and repeated attempts to remove it with FB forceps failed. The endoscopist recommended surgical removal. The father was informed of the patient’s condition, but he refused, in his capacity as guardian, to give consent for laparotomy. He believed that such a low-lying FB would exit naturally. Nine months later, the patient’s mother, who became the legal guardian after the father’s death, gave consent for surgery. During that interval, no further rectal bleeding was noted. However,
CURRENT SURGERY • © 2005 by the Association of Program Directors in Surgery Published by Elsevier Inc.
0149-7944/05/$30.00 doi:10.1016/j.cursur.2004.12.014
419
aggregates in the submucosa and serosa, some of which had germinal centers. Focal areas of necrosis were present in the muscular coat.
DISCUSSION
FIGURE 1. Colonoscopic image of the sigmoid colon shows a yellow flat piece of plastic (end-on view), which is partially covered with blood and adjoining an injury-induced ulcer.
Perforation occurs in less than 1% of ingested FBs, which are usually sharp or pointed.2 Perforation tends to occur in natural narrowings and angulations. The rectosigmoid region is the second most common site of intestinal perforation by an ingested FB, following the ileocecal region.4,7 Apart from the reduction in the caliber of the intestinal lumen, there is an important change in direction in intestinal transit in this area between the mobile sigmoid and the more-or-less fixed rectum.4 Local pathologic factors also increase the probability of perforation such as IBD, adhesions, diverticular disease, Meckel’s diverticulum, tumors, and hernias.3,7 Intestinal perforations by FBs may be acute or chronic. Acute perforation, which is most likely caused by a pointed FB, tends to occur in the small intestine. Chronic perforation is most likely caused by a nonpointed FB and tends to occur in the sigmoid colon.2 Acute perforations are usually clinically re-
the patient suffered several episodes of left lower quadrant abdominal pain. These episodes were not associated with signs of acute abdomen or intestinal obstruction. A preoperative upright plain abdominal X-ray was normal. A single contrast barium enema showed stenosis and distortion of the proximal part of the sigmoid colon, suggestive of inflammatory bowel disease (IBD) (Fig. 2). Repeat colonoscopy confirmed the presence of the FB in a narrowed segment of the sigmoid colon with granuloma (Fig. 3); colonoscopic extraction failed again. The remainder of the colon up to the cecum appeared normal. During the preoperative bowel preparation, the patient suffered a febrile respiratory tract infection and surgery was postponed for 3 months. The patient finally underwent surgery 13 months after his first presentation with rectal bleeding. A third colonoscopy showed similar findings to the previous study. Operation, through an extended lower midline abdominal incision, revealed a moderate amount of clear serous fluid in the peritoneal cavity. The descending colon, sigmoid colon, and upper rectum were mobilized. A mass of fibrous tissue reaction at the rectosigmoid sealing an old perforation was adherent to the left iliac wall. The fibrous mass involved the left iliac vessels and left ureter. The recovered FB was a rectangular piece of plastic with sharp edges, 5 ⫻ 6 cm and 0.5 cm in thickness. To avoid injury to the iliac vessels and ureter, the ends of the colon were transected and end-to-end anastomosis was done. Convalescence was uneventful. Histological examination of the colon showed a chronic granulomatous reaction resembling IBD. The mucosa was infiltrated with a large number of round cells with the occasional presence of crypt abscesses. There were lymphoid
FIGURE 2. Barium enema shows stenosis and distortion of the proximal part of the sigmoid colon, which is suggestive of IBD.
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CURRENT SURGERY • Volume 62/Number 4 • July/August 2005
FIGURE 3. Colonoscopic image of the sigmoid colon shows a yellow flat piece of plastic (side view), with overgrown granuloma.
markable, and the history is short as patients present with acute peritonitis. The FB is probably pushed through the wall by peristaltic activity. At operation, no adhesions are found walling off the inflammatory process.2 In contrast, patients with chronic perforation (such as ours) may present with nonspecific complaints of subacute or chronic nature. The presumed mechanism is ulceration caused by pressure necrosis; inflammation may be limited by the formation of adhesions, abscesses, or inflammatory masses. This mechanism seems to be supported by the multiple reports of prolonged time between ingestion and perforation.8 Because of the frequent lack of a history of FB ingestion and the nonspecific clinical manifestations, diagnosis of intestinal perforation is seldom made preoperatively.3,4 It is unusual, even in acute perforations, to see a pneumo-peritoneum on a preoperative abdominal film as the perforation is usually caused by progressive impaction of the object in the intestinal wall. This result allows the perforation to be covered with fibrin and adjacent loops and prevents the exodus of gas and fluid into the peritoneal cavity.4 There are several interesting aspects of this case. First, there is the uncertainty of whether the FB was ingested or introduced per anum. Mentally retarded subjects are a high-risk group for both, and the patient could not provide a history. The big size of the FB favors the anal over the oral route, as the rectum can accommodate large objects. To our knowledge, no case of intestinal perforation by such a foreign body (a flat piece of plastic) has been reported. Second, the presentation was with a single nonrecurrent episode of bleeding per rectum. Only one eighth of colorectal FBs present with rectal bleeding.9 The diCURRENT SURGERY • Volume 62/Number 4 • July/August 2005
agnosis of lower intestinal FBs should be considered in the differential diagnosis of hematochezia in mentally retarded patients. Third, the presence of a colonic FB, but not the resulting perforation, was known through colonoscopy long before surgery. In most cases of intestinal perforation, culpable, nonradiopaque FBs are only discovered during operation. It is fairly common for FBs to be impacted in areas of the intestine affected by IBD. If the diagnosis of IBD is not known, obstruction by FBs may lead to early diagnosis and prevent more serious morbidity.10 This outcome has been gracefully described as being caused by “the propitious pit.”11 The reverse situation, in which an impacted FB produces an IBD-like reaction in a normal area of intestine, seems to be rare.12,13 Our case provides an insight into the natural history of this process, thanks to the over-a-year delay between diagnosis and removal of the FB. The most probable sequence of events is as follows. At first, the FB caused colonic ulceration through pressure necrosis, which manifested with rectal bleeding. Chronic perforation of the colonic wall then followed, which caused gross formation of extra-intestinal adhesions to the pelvic wall. The colonic wall reacted with a chronic granulomatous process, which gave pathologic and radiographic pictures resembling IBD. The patient suffered intermittent bouts of lower abdominal pain, which retrospectively are accounted for by a slow process of perforation.
CONCLUSION Intestinal perforation by FBs has several presentations and is a difficult diagnosis to be made preoperatively. The condition is indistinguishable from acute abdomen, mimics IBD, and is a differential diagnosis for bleeding per rectum. A high index of suspicion for gastrointestinal FBs should be maintained in mentally retarded subjects presenting with abdominal complaints. Impacted colonic FBs should be removed early as they are liable to cause perforation if left without treatment.
REFERENCES 1. Lyons MF 2nd, Tsuchida AM. Foreign bodies of the gas-
trointestinal tract. Med Clin North Am. 1993;77:11011114. 2. Henderson FF, Gaston EA. Ingested foreign body in the
gastrointestinal tract. Arch Surg. 1938;36:66-95. 3. McPherson RC, Karlan M, Williams RD. Foreign body
perforation of the intestinal tract. Am J Surg. 1957;94: 564-566. 4. Pinero Madrona A, Fernandez Hernandez JA, Carrasco
Prats M, Riquelme Riquelme J, Parrila Paricio P. Intestinal perforation by foreign bodies. Eur J Surg. 2000;166: 307-309. 421
5. Wolf L, Geraci K. Colonoscopic removal of balloons from
the bowel. Gastrointest Endosc. 1977;24:41. 6. Busch DB, Starling JR. Rectal foreign bodies: case reports
10. Wu ML, DeVos WC, Flamm SL. Desiccant recovered,
Crohn’s disease discovered. Am J Gastroenterol. 1998;93: 2595-2597.
and a comprehensive review of the world’s literature. Surgery. 1986;100:512-519.
11. Price JE, Michel SL, Morgenstern L. Fruit pit obstruction.
7. Macmanus JE. Perforations of the intestine by ingested
12. O’Gorman MA, Boyer RS, Jackson WD. Toothpick for-
foreign bodies. Am J Surg. 1941;53:393-402. 8. McCanse DE, Kurchin A, Hinshaw JR. Gastrointestinal
foreign bodies. Am J Surg. 1981;142:335-337. 9. Cohen JS, Sackier JM. Management of colorectal foreign
bodies. J R Coll Surg Edinb. 1996;41:312-315.
422
“The propitious pit.” Arch Surg. 1976;111:773-775. eign body perforation and migration mimicking Crohn’s disease in a child. J Pediatr Gastroenterol Nutr. 1996;23: 628-630. 13. Segal I, Nouri MA, Hamilton DG, et al. Foreign-body
ileitis. A case report. S Afr Med J. 1980;58:421-422.
CURRENT SURGERY • Volume 62/Number 4 • July/August 2005
Chronic Perforation of the Sigmoid Colon by Foreign Body Fawzi E. Ali, MS,* Waleed A. Al-Busairi, MD,* Emad Y. Esbaita, MS,* and Mahmoud A. Al-Bustan, HSD† *Medical Rehabilitation Center, Kuwait, and †Faculty of Medicine, Kuwait University, Kuwait Colorectal foreign bodies (FBs) may be ingested or introduced transanally and then migrate proximally. Without a reliable history, it may be impossible to determine which way a certain colorectal FB gained access. We present a case of a nonverbal mentally retarded boy with a flat piece of plastic impacted in the sigmoid colon, the colonoscopic extraction of which failed. He underwent laparotomy more than a year later to remove the FB, where chronic perforation of the sigmoid colon was discovered. The perforation was sealed with extensive adhesions to the pelvic wall, and histologically, the colon showed a chronic granulomatous reaction. We discuss the types, presentations, and diagnosis of intestinal perforation with FBs. Chronic perforation may present with radiologic and pathologic features that suggest inflammatory bowel disease. (Curr Surg 62:419-422. © 2005 by the Association of Program Directors in Surgery.)
Absent an accurate medical history, it may be impossible for a physician to determine if a certain colorectal FB was ingested or passed per anum. Most people who accidentally ingest FBs are unaware of the incident,3,7 and most people who insert FBs per anum give misleading history to avoid social embarrassment.1,6 Mentally ill patients may give an unreliable history, and mentally retarded subjects may be too cognitively impaired to give a history. The nature of the FB can be helpful in deciding which way it entered the body as chicken bones, tooth picks, and dental prostheses are obviously ingested. Sex toys such as dildos and vibrators are obviously inserted transanally. Colorectal FBs, which by their sheer size and shape, could not have traversed the upper gastrointestinal tract (eg, bottles and jars) must have been passed up through the anus.
KEY WORDS: foreign body, intestinal perforation, mental
CASE REPORT
retardation, sigmoid colon
INTRODUCTION Colorectal foreign bodies (FBs) may be ingested or introduced by the anal route.1 Although most ingested FBs traverse the length of the gastrointestinal tract and exit naturally, complications such as impaction, obstruction, perforation, and hemorrhage occasionally occur.2,3 The most common sites for narrowing and impaction are the upper and lower esophageal sphincters, the pylorus, and the ileocecal valve.1 Still, some FBs can negotiate these hurdles and get impacted lower down in the colon, rectum, and anal canal.4 Foreign body ingestion in adults is associated with denture-wearing in elderly people, alcohol and drug abuse, incarceration, mental retardation, and mental illness.1 On the other hand, FBs introduced transanally can migrate proximally up to the hepatic flexure.5 Such FBs are mostly inserted by the patient or a partner for sexual stimulation, but other causes include relief of anorectal conditions, sexual assault, medical instrumentation, accidental introduction, and psychiatric illness.1,6 Correspondence: Inquiries to Fawzi E. Ali, MS, P.O. Box 1240 Surra, Code 45713, Kuwait; fax: (965) 4875409; e-mail: [email protected]
A 16-year-old Kuwaiti boy presented with an episode of bleeding per rectum lasting for 2 hours. He was severely retarded and nonverbal. He had been institutionalized since the age of 8 years at a state-run residential facility in Kuwait. There was no history of gastrointestinal disease or abdominal surgery. He took no medications. Abdominal examination was normal, and rectal examination failed to find a source for the bleeding. The laboratory data were significant only for polymorph leukocytosis (Total white blood cell count 20 ⫻ 109/l) and a moderate degree of normocytic normochromic anemia (red blood cell count 3.75 ⫻ 1012/l, Hgb 11.5 g/dl, and Hct 33.4%). Ultrasound scan of the abdomen was unremarkable. At colonoscopy, no source of bleeding was observed up to the midsigmoid, where a yellow-colored plastic FB was found adjoining an injury-induced ulcer (Fig. 1). The FB was lodged in position, and repeated attempts to remove it with FB forceps failed. The endoscopist recommended surgical removal. The father was informed of the patient’s condition, but he refused, in his capacity as guardian, to give consent for laparotomy. He believed that such a low-lying FB would exit naturally. Nine months later, the patient’s mother, who became the legal guardian after the father’s death, gave consent for surgery. During that interval, no further rectal bleeding was noted. However,
CURRENT SURGERY • © 2005 by the Association of Program Directors in Surgery Published by Elsevier Inc.
0149-7944/05/$30.00 doi:10.1016/j.cursur.2004.12.014
419
aggregates in the submucosa and serosa, some of which had germinal centers. Focal areas of necrosis were present in the muscular coat.
DISCUSSION
FIGURE 1. Colonoscopic image of the sigmoid colon shows a yellow flat piece of plastic (end-on view), which is partially covered with blood and adjoining an injury-induced ulcer.
Perforation occurs in less than 1% of ingested FBs, which are usually sharp or pointed.2 Perforation tends to occur in natural narrowings and angulations. The rectosigmoid region is the second most common site of intestinal perforation by an ingested FB, following the ileocecal region.4,7 Apart from the reduction in the caliber of the intestinal lumen, there is an important change in direction in intestinal transit in this area between the mobile sigmoid and the more-or-less fixed rectum.4 Local pathologic factors also increase the probability of perforation such as IBD, adhesions, diverticular disease, Meckel’s diverticulum, tumors, and hernias.3,7 Intestinal perforations by FBs may be acute or chronic. Acute perforation, which is most likely caused by a pointed FB, tends to occur in the small intestine. Chronic perforation is most likely caused by a nonpointed FB and tends to occur in the sigmoid colon.2 Acute perforations are usually clinically re-
the patient suffered several episodes of left lower quadrant abdominal pain. These episodes were not associated with signs of acute abdomen or intestinal obstruction. A preoperative upright plain abdominal X-ray was normal. A single contrast barium enema showed stenosis and distortion of the proximal part of the sigmoid colon, suggestive of inflammatory bowel disease (IBD) (Fig. 2). Repeat colonoscopy confirmed the presence of the FB in a narrowed segment of the sigmoid colon with granuloma (Fig. 3); colonoscopic extraction failed again. The remainder of the colon up to the cecum appeared normal. During the preoperative bowel preparation, the patient suffered a febrile respiratory tract infection and surgery was postponed for 3 months. The patient finally underwent surgery 13 months after his first presentation with rectal bleeding. A third colonoscopy showed similar findings to the previous study. Operation, through an extended lower midline abdominal incision, revealed a moderate amount of clear serous fluid in the peritoneal cavity. The descending colon, sigmoid colon, and upper rectum were mobilized. A mass of fibrous tissue reaction at the rectosigmoid sealing an old perforation was adherent to the left iliac wall. The fibrous mass involved the left iliac vessels and left ureter. The recovered FB was a rectangular piece of plastic with sharp edges, 5 ⫻ 6 cm and 0.5 cm in thickness. To avoid injury to the iliac vessels and ureter, the ends of the colon were transected and end-to-end anastomosis was done. Convalescence was uneventful. Histological examination of the colon showed a chronic granulomatous reaction resembling IBD. The mucosa was infiltrated with a large number of round cells with the occasional presence of crypt abscesses. There were lymphoid
FIGURE 2. Barium enema shows stenosis and distortion of the proximal part of the sigmoid colon, which is suggestive of IBD.
420
CURRENT SURGERY • Volume 62/Number 4 • July/August 2005
FIGURE 3. Colonoscopic image of the sigmoid colon shows a yellow flat piece of plastic (side view), with overgrown granuloma.
markable, and the history is short as patients present with acute peritonitis. The FB is probably pushed through the wall by peristaltic activity. At operation, no adhesions are found walling off the inflammatory process.2 In contrast, patients with chronic perforation (such as ours) may present with nonspecific complaints of subacute or chronic nature. The presumed mechanism is ulceration caused by pressure necrosis; inflammation may be limited by the formation of adhesions, abscesses, or inflammatory masses. This mechanism seems to be supported by the multiple reports of prolonged time between ingestion and perforation.8 Because of the frequent lack of a history of FB ingestion and the nonspecific clinical manifestations, diagnosis of intestinal perforation is seldom made preoperatively.3,4 It is unusual, even in acute perforations, to see a pneumo-peritoneum on a preoperative abdominal film as the perforation is usually caused by progressive impaction of the object in the intestinal wall. This result allows the perforation to be covered with fibrin and adjacent loops and prevents the exodus of gas and fluid into the peritoneal cavity.4 There are several interesting aspects of this case. First, there is the uncertainty of whether the FB was ingested or introduced per anum. Mentally retarded subjects are a high-risk group for both, and the patient could not provide a history. The big size of the FB favors the anal over the oral route, as the rectum can accommodate large objects. To our knowledge, no case of intestinal perforation by such a foreign body (a flat piece of plastic) has been reported. Second, the presentation was with a single nonrecurrent episode of bleeding per rectum. Only one eighth of colorectal FBs present with rectal bleeding.9 The diCURRENT SURGERY • Volume 62/Number 4 • July/August 2005
agnosis of lower intestinal FBs should be considered in the differential diagnosis of hematochezia in mentally retarded patients. Third, the presence of a colonic FB, but not the resulting perforation, was known through colonoscopy long before surgery. In most cases of intestinal perforation, culpable, nonradiopaque FBs are only discovered during operation. It is fairly common for FBs to be impacted in areas of the intestine affected by IBD. If the diagnosis of IBD is not known, obstruction by FBs may lead to early diagnosis and prevent more serious morbidity.10 This outcome has been gracefully described as being caused by “the propitious pit.”11 The reverse situation, in which an impacted FB produces an IBD-like reaction in a normal area of intestine, seems to be rare.12,13 Our case provides an insight into the natural history of this process, thanks to the over-a-year delay between diagnosis and removal of the FB. The most probable sequence of events is as follows. At first, the FB caused colonic ulceration through pressure necrosis, which manifested with rectal bleeding. Chronic perforation of the colonic wall then followed, which caused gross formation of extra-intestinal adhesions to the pelvic wall. The colonic wall reacted with a chronic granulomatous process, which gave pathologic and radiographic pictures resembling IBD. The patient suffered intermittent bouts of lower abdominal pain, which retrospectively are accounted for by a slow process of perforation.
CONCLUSION Intestinal perforation by FBs has several presentations and is a difficult diagnosis to be made preoperatively. The condition is indistinguishable from acute abdomen, mimics IBD, and is a differential diagnosis for bleeding per rectum. A high index of suspicion for gastrointestinal FBs should be maintained in mentally retarded subjects presenting with abdominal complaints. Impacted colonic FBs should be removed early as they are liable to cause perforation if left without treatment.
REFERENCES 1. Lyons MF 2nd, Tsuchida AM. Foreign bodies of the gas-
trointestinal tract. Med Clin North Am. 1993;77:11011114. 2. Henderson FF, Gaston EA. Ingested foreign body in the
gastrointestinal tract. Arch Surg. 1938;36:66-95. 3. McPherson RC, Karlan M, Williams RD. Foreign body
perforation of the intestinal tract. Am J Surg. 1957;94: 564-566. 4. Pinero Madrona A, Fernandez Hernandez JA, Carrasco
Prats M, Riquelme Riquelme J, Parrila Paricio P. Intestinal perforation by foreign bodies. Eur J Surg. 2000;166: 307-309. 421
5. Wolf L, Geraci K. Colonoscopic removal of balloons from
the bowel. Gastrointest Endosc. 1977;24:41. 6. Busch DB, Starling JR. Rectal foreign bodies: case reports
10. Wu ML, DeVos WC, Flamm SL. Desiccant recovered,
Crohn’s disease discovered. Am J Gastroenterol. 1998;93: 2595-2597.
and a comprehensive review of the world’s literature. Surgery. 1986;100:512-519.
11. Price JE, Michel SL, Morgenstern L. Fruit pit obstruction.
7. Macmanus JE. Perforations of the intestine by ingested
12. O’Gorman MA, Boyer RS, Jackson WD. Toothpick for-
foreign bodies. Am J Surg. 1941;53:393-402. 8. McCanse DE, Kurchin A, Hinshaw JR. Gastrointestinal
foreign bodies. Am J Surg. 1981;142:335-337. 9. Cohen JS, Sackier JM. Management of colorectal foreign
bodies. J R Coll Surg Edinb. 1996;41:312-315.
422
“The propitious pit.” Arch Surg. 1976;111:773-775. eign body perforation and migration mimicking Crohn’s disease in a child. J Pediatr Gastroenterol Nutr. 1996;23: 628-630. 13. Segal I, Nouri MA, Hamilton DG, et al. Foreign-body
ileitis. A case report. S Afr Med J. 1980;58:421-422.
CURRENT SURGERY • Volume 62/Number 4 • July/August 2005