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Colonoscopic removal of a denture migrated in the appendix
AT THE FOCAL POINT Massimo Raimondo, MD, Associate Editor for Focal Points
Colonoscopic removal of a denture migrated in the appendix
A 76-year-old woman presented because of possible accidental ingestion of a denture. Two days before her admission, she noticed that she had lost a denture from the right lower gingiva implanted 20 years previously. On admission, she was in otherwise fair condition, and she had no contributing abdominal symptoms. A radiograph of the abdomen showed a foreign body in the right lower abdomen (A). We determined that the foreign body had already passed the ileocecal valve, and thus we decided to follow up with the use of laxatives. However, a radiograph 2 days after admission showed that the foreign body still remained in the same position, although she had regular bowel movements. With a diagnosis of foreign body retention in the cecum, we performed endoscopic examination. Colonoscopy
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revealed no foreign body in the cecum at first glance (B), but as the colonoscope pushed the orifice of the appendix, a denture was pushed out gradually, and part of the denture appeared at the surface (C). Subsequently, we successfully removed the denture using a polypectomy snare device (D). The patient’s clinical course after the procedure was not complicated, and she showed no sign of subsequent appendicitis.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Volume
-,
No.
-
: 2017 GASTROINTESTINAL ENDOSCOPY 1
At the Focal Point
Kazuki Ikeda, MD, PhD, Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Osaka, Takefumi Nakamura, MD, PhD, Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Kansai Electric Power Medical Research Institute, Osaka, Japan, Suguru Uose, MD, PhD, Hitoshi Someda, MD, PhD, Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Osaka, Japan, Tsutomu
Chiba, MD, PhD, Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Osaka, Japan, Kansai Electric Power Medical Research Institute, Osaka, Japan, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Postgraduate School of Medicine, Kyoto University, Kyoto, Japan https://doi.org/10.1016/j.gie.2017.10.018
Commentary Foreign bodies lodged in the appendix have been reported as rare, but they are more common than we may expect. The last review by Kingler et al published in 1998 compiled 256 cases from the last 100 years. The foreign bodies range from fishbone and needles to toothpicks and dentures, among others. Serious adverse events have been reported (appendicitis, ileocecal fistula, perforation, bleeding, peritonitis). In this review, the majority of foreign bodies were removed surgically, but few were removed endoscopically. After 1998, 8 cases that attempted endoscopic removal have been reported. In 2 cases, despite the use of multiple instruments for endoscopic foreign body extraction, the attempt was unsuccessful. Five other published cases, including the one presented here, underwent successful retrieval with colonoscopy before the development of acute appendicitis. Different tools such as biopsy forceps and polypectomy snares have been used with and without fluoroscopy guidance. The presented case denotes an outstanding removal of the appendix foreign body (denture) with a polypectomy snare without adverse events. Importantly, when a case of foreign body ingestion is being managed, the imaging could show the foreign body in the right side of the colon, near the ileocecal valve and this should alert the endoscopist to be prepared and anticipate that the foreign body could be lodged at the appendiceal orifice or inside the appendix. There is no rule on what instruments to use for an appendix foreign body extraction, which depends on the type of foreign body. The focal point is that when an appendiceal foreign body is suspected (by imaging), colonoscopy extraction is indicated as long as there is no evidence of acute appendicitis. Roberto Simons, MD Gastroenterology Fellow, Cleveland Clinic Cleveland, Ohio Massimo Raimondo, MD Associate Editor for Focal Points
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2017
www.giejournal.org
Colonoscopic removal of a denture migrated in the appendix
A 76-year-old woman presented because of possible accidental ingestion of a denture. Two days before her admission, she noticed that she had lost a denture from the right lower gingiva implanted 20 years previously. On admission, she was in otherwise fair condition, and she had no contributing abdominal symptoms. A radiograph of the abdomen showed a foreign body in the right lower abdomen (A). We determined that the foreign body had already passed the ileocecal valve, and thus we decided to follow up with the use of laxatives. However, a radiograph 2 days after admission showed that the foreign body still remained in the same position, although she had regular bowel movements. With a diagnosis of foreign body retention in the cecum, we performed endoscopic examination. Colonoscopy
www.giejournal.org
revealed no foreign body in the cecum at first glance (B), but as the colonoscope pushed the orifice of the appendix, a denture was pushed out gradually, and part of the denture appeared at the surface (C). Subsequently, we successfully removed the denture using a polypectomy snare device (D). The patient’s clinical course after the procedure was not complicated, and she showed no sign of subsequent appendicitis.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Volume
-,
No.
-
: 2017 GASTROINTESTINAL ENDOSCOPY 1
At the Focal Point
Kazuki Ikeda, MD, PhD, Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Osaka, Takefumi Nakamura, MD, PhD, Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Kansai Electric Power Medical Research Institute, Osaka, Japan, Suguru Uose, MD, PhD, Hitoshi Someda, MD, PhD, Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Osaka, Japan, Tsutomu
Chiba, MD, PhD, Department of Gastroenterology and Hepatology, Kansai Electric Power Hospital, Osaka, Japan, Kansai Electric Power Medical Research Institute, Osaka, Japan, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Postgraduate School of Medicine, Kyoto University, Kyoto, Japan https://doi.org/10.1016/j.gie.2017.10.018
Commentary Foreign bodies lodged in the appendix have been reported as rare, but they are more common than we may expect. The last review by Kingler et al published in 1998 compiled 256 cases from the last 100 years. The foreign bodies range from fishbone and needles to toothpicks and dentures, among others. Serious adverse events have been reported (appendicitis, ileocecal fistula, perforation, bleeding, peritonitis). In this review, the majority of foreign bodies were removed surgically, but few were removed endoscopically. After 1998, 8 cases that attempted endoscopic removal have been reported. In 2 cases, despite the use of multiple instruments for endoscopic foreign body extraction, the attempt was unsuccessful. Five other published cases, including the one presented here, underwent successful retrieval with colonoscopy before the development of acute appendicitis. Different tools such as biopsy forceps and polypectomy snares have been used with and without fluoroscopy guidance. The presented case denotes an outstanding removal of the appendix foreign body (denture) with a polypectomy snare without adverse events. Importantly, when a case of foreign body ingestion is being managed, the imaging could show the foreign body in the right side of the colon, near the ileocecal valve and this should alert the endoscopist to be prepared and anticipate that the foreign body could be lodged at the appendiceal orifice or inside the appendix. There is no rule on what instruments to use for an appendix foreign body extraction, which depends on the type of foreign body. The focal point is that when an appendiceal foreign body is suspected (by imaging), colonoscopy extraction is indicated as long as there is no evidence of acute appendicitis. Roberto Simons, MD Gastroenterology Fellow, Cleveland Clinic Cleveland, Ohio Massimo Raimondo, MD Associate Editor for Focal Points
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2017
www.giejournal.org