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Colonoscopic removal of a foreign body causing colocutaneous fistulas
Adequacy of diameter can be confirmed by passing a Maloney dilator of a size slightly larger than the endoscope. Passage of the dilator should also open the cricopharyngeus and make it easier for the patient to swallow the instrument. The Maloney dilator was not used in this study because it was assumed that an adequate diameter was present if the patient did not have early dysphagia for solid foods. Sanders 2 has described a balloon-tip for the flexible fiberoptic endoscope which facilitates blind passage of the instrument, but it has the disadvantage of blocking the visual control of the tip as soon as the balloon is inflated. Even when passing the endoscope under direct vision, the operator never knows for certain whether the esophagus lies to the left or right of midline. Some probing with the endoscope is necessary to find the
lumen since it is rarely located precisely in the midline. Probing with the guide under direct vision will indicate the safe passage for the endoscope. The guide for peroral endoscopy can be used with any flexible fiberoptic endoscope which has a biopsy channel large enough to accommodate its 2.1-mm diameter. Although the guide in this study was used with ACMI endoscopes, it could have been used with any Olympus, Fujinon, Pentax, or similar equipment that will allow passage of a full-size biopsy forceps.
REFERENCES 1. MANDElSTAM P, SUGAWA
2.
C,
SilVIS SE, NEBEl
OT,
ROGERS
BHG:
Complications associated with esophagogastroduodenoscopy and with esophageal dilation. Gastrointest Endosc 23:16, 1976 SANDERS )H: Balloon obturator can ease introduction of blunttip endoscope. Gastrointest Endosc 21:176, 1975
Colonoscopic removal of a foreign body causing colocutaneous fistulas N. Rao Vemula, MD Juan Madariaga, MD Douglas l. Brand, MD Herbert Hershey, MD
Swallowing a foreign body is not an infrequent event, happening most often among children and psychotic individuals. We report a patient who developed colocutaneous fistulas and a jejunal perforation after foreign body ingestion. We describe the endoscopic removal of pencils from a gastrojejunostomy and the cecum. CASE REPORT
A 52-year-old diabetic schizophrenic man was admitted to the Northport Veterans Administration Medical Center with a 2-month history of diarrhea and vomiting. Seven years previously, the patient had had a Billroth II gastrectomy and vagotomy for peptic ulcer disease. Physical examination on admission revealed a slender man in no apparent distress with normal vital signs. On abdominal palpation, there were two indurated swellings in the right iliac fossa and right inguinal area, measuring 2 by 2 cm, with discharging sinuses. An abdominal x-ray showed multiple long, opaque foreign bodies thought to be lying in the efferent loop of the gastrojejunostomy and in the area of the cecum and ascending colon (Fig. 1). A fistulogram through one sinus tract revealed communication from the skin to the cecum and ascending colon. With a surgical team standing by, endoFrom the Medical and Surgical Services, Veterans Administration Medical Center, Northport, New York, and the Division of Gastroentero/ogy-Hepato/ogy, Department of Medicine, and the Department of Surgery, State University of New York, Stony Brook, New York. Reprint requests: Douglas L. Brand, MD, Division of Gastroenterology-Hepatology, Health Sciences Center, State University of New York, Stony Brook, New York 11794. VOLUME 28, NO.3, 1982
Figure 1. Admission radiograph showing ingested foreign bodies in jejunal and cecal areas (arrows). scopic retrieval of the foreign bodies was attempted, using a fiberoptic gastroscope and colonoscope. Four full length wood pencils were removed from the gastrojejunostomy and one from the cecum, using a polypectomy snare. None of the pencils had a sharp or pointed edge. Following the removal of the pencil from the cecum, the fistulous tracts healed. However, 2 weeks later, the patient suddenly developed signs of an acute abdomen and an exploratory laparotomy revealed perforation of the midjejunum with peritonitis. A pencil was removed from the jejunum and the 195
perforation was closed. The patient had an uneventful postoperative course and was discharged from the hospital.
DISCUSSION Ingestion of foreign bodies can produce difficult diagnostic problems because concealment of the event of ingestion is common in the patients at risk. Complications such as asphyxiation or perforation occur in about 1% of cases, with perforation sometimes causing infection, hemorrhage, or fistulization. 1 Perforation by a foreign body is more likely if the object is long or sharp. Perforation is also enhanced by a history of previous bowel surgery, since adhesions or anastomoses interfere with normal passage of the object. Our patient had both risk factors. Formation of colocutaneous fistulas represents a unique complication of foreign bodies perforating the intestine, to be added to penetrations from the gut to the liver, kidney, bladder, and great vessels. 2 - 6 Foreign bodies with sharp edges or points present a special problem to the endoscopist. Rogers and coworkers? have recently reported the use of an endoscopic overtube that was advanced from its initial position on the distal end of the endoscope over a guitar pick lodged in the esophagus. The whole assembly was then withdrawn, with the foreign body safely inside the overtube. This technique may have merit for removing sharp objects from the colon as well. All the blunt pencils seen on the admission radiographs of our patient were removed endoscopically. The subsequent perforation was by a pencil either not seen on the initial radiography or swallowed after endoscopy, demonstrating the need for postremoval
196
contrast radiography to ensure that all foreign bodies have been removed. Colonoscopic removal of foreign bodies has been described before 8 - 1o and has a legitimate role in the management of colonic foreign bodies. If the colonoscopic approach is limited to objects of a size and shape safe for removal, a surgical team is alerted and contrast radiography is done promptly postcolonoscopy to ensure complete removal of all ingested foreign bodies; then, colonoscopic retrieval can be performed safely. REFERENCES 1. MCPHERSON RC, KARLAN M, WILLIAMS RD: Foreign body perforation of the intestinal tract. Am 1 Surg 94:564, 1957 2. ABEL RM, FISCHER jE, HENDREN WH: Penetration of the alimentary tract by a foreign body with migration to the liver. Arch Surg 102:227, 1971 3. BAIRD JM, SPENCE HM: Ingested foreign bodies migrating to the kidney from the gastrointestinal tract. 1 Urol 99:675, 1968 4. NELSON AM, FRANK HD, TAUBIN HL: Colovesical fistula secondary to foreign-body perforation of the sigmoid colon. Dis Colon Rectum 22:559, 1979 5. HAMBRICK E, RAO TR, LIM LT: jejunoaortic fistula from ingested seamstress needle. Arch Surg 114:732, 1979 6. JUSTINIANI FR, WIGODA L, ORTEGA RS: Duodenocaval fistula due to toothpick perforation. lAMA 227:788, 1974 7. ROGERS BHG, KOT C, MEIRI S, EpSTEIN M: Further studies on an over-tube used with the flexible fiberoptic esophagogastroduodenoscope to remove foreign bodies (abstract). Gastrointest Endosc 26:76, 1980 8. SORENSON RM, BOND JH )R: Colonoscopic removal of a foreign body from the cecum. Gastrointest Endosc 21:134, 1975 9. WOLF L, GERACI K: Colonoscopic removal of balloons from the bowel. Gastrointest Endosc 24:41, 1977 10. OEHLER JR, DENT TL, IBRAHIM MAH, GRACIE WA JR: Endoscopic identification and removal of an unusual symptomatic colonic foreign body. Dig Dis Sci 24:237, 1979
GASTROINTESTINAL ENDOSCOPY
lumen since it is rarely located precisely in the midline. Probing with the guide under direct vision will indicate the safe passage for the endoscope. The guide for peroral endoscopy can be used with any flexible fiberoptic endoscope which has a biopsy channel large enough to accommodate its 2.1-mm diameter. Although the guide in this study was used with ACMI endoscopes, it could have been used with any Olympus, Fujinon, Pentax, or similar equipment that will allow passage of a full-size biopsy forceps.
REFERENCES 1. MANDElSTAM P, SUGAWA
2.
C,
SilVIS SE, NEBEl
OT,
ROGERS
BHG:
Complications associated with esophagogastroduodenoscopy and with esophageal dilation. Gastrointest Endosc 23:16, 1976 SANDERS )H: Balloon obturator can ease introduction of blunttip endoscope. Gastrointest Endosc 21:176, 1975
Colonoscopic removal of a foreign body causing colocutaneous fistulas N. Rao Vemula, MD Juan Madariaga, MD Douglas l. Brand, MD Herbert Hershey, MD
Swallowing a foreign body is not an infrequent event, happening most often among children and psychotic individuals. We report a patient who developed colocutaneous fistulas and a jejunal perforation after foreign body ingestion. We describe the endoscopic removal of pencils from a gastrojejunostomy and the cecum. CASE REPORT
A 52-year-old diabetic schizophrenic man was admitted to the Northport Veterans Administration Medical Center with a 2-month history of diarrhea and vomiting. Seven years previously, the patient had had a Billroth II gastrectomy and vagotomy for peptic ulcer disease. Physical examination on admission revealed a slender man in no apparent distress with normal vital signs. On abdominal palpation, there were two indurated swellings in the right iliac fossa and right inguinal area, measuring 2 by 2 cm, with discharging sinuses. An abdominal x-ray showed multiple long, opaque foreign bodies thought to be lying in the efferent loop of the gastrojejunostomy and in the area of the cecum and ascending colon (Fig. 1). A fistulogram through one sinus tract revealed communication from the skin to the cecum and ascending colon. With a surgical team standing by, endoFrom the Medical and Surgical Services, Veterans Administration Medical Center, Northport, New York, and the Division of Gastroentero/ogy-Hepato/ogy, Department of Medicine, and the Department of Surgery, State University of New York, Stony Brook, New York. Reprint requests: Douglas L. Brand, MD, Division of Gastroenterology-Hepatology, Health Sciences Center, State University of New York, Stony Brook, New York 11794. VOLUME 28, NO.3, 1982
Figure 1. Admission radiograph showing ingested foreign bodies in jejunal and cecal areas (arrows). scopic retrieval of the foreign bodies was attempted, using a fiberoptic gastroscope and colonoscope. Four full length wood pencils were removed from the gastrojejunostomy and one from the cecum, using a polypectomy snare. None of the pencils had a sharp or pointed edge. Following the removal of the pencil from the cecum, the fistulous tracts healed. However, 2 weeks later, the patient suddenly developed signs of an acute abdomen and an exploratory laparotomy revealed perforation of the midjejunum with peritonitis. A pencil was removed from the jejunum and the 195
perforation was closed. The patient had an uneventful postoperative course and was discharged from the hospital.
DISCUSSION Ingestion of foreign bodies can produce difficult diagnostic problems because concealment of the event of ingestion is common in the patients at risk. Complications such as asphyxiation or perforation occur in about 1% of cases, with perforation sometimes causing infection, hemorrhage, or fistulization. 1 Perforation by a foreign body is more likely if the object is long or sharp. Perforation is also enhanced by a history of previous bowel surgery, since adhesions or anastomoses interfere with normal passage of the object. Our patient had both risk factors. Formation of colocutaneous fistulas represents a unique complication of foreign bodies perforating the intestine, to be added to penetrations from the gut to the liver, kidney, bladder, and great vessels. 2 - 6 Foreign bodies with sharp edges or points present a special problem to the endoscopist. Rogers and coworkers? have recently reported the use of an endoscopic overtube that was advanced from its initial position on the distal end of the endoscope over a guitar pick lodged in the esophagus. The whole assembly was then withdrawn, with the foreign body safely inside the overtube. This technique may have merit for removing sharp objects from the colon as well. All the blunt pencils seen on the admission radiographs of our patient were removed endoscopically. The subsequent perforation was by a pencil either not seen on the initial radiography or swallowed after endoscopy, demonstrating the need for postremoval
196
contrast radiography to ensure that all foreign bodies have been removed. Colonoscopic removal of foreign bodies has been described before 8 - 1o and has a legitimate role in the management of colonic foreign bodies. If the colonoscopic approach is limited to objects of a size and shape safe for removal, a surgical team is alerted and contrast radiography is done promptly postcolonoscopy to ensure complete removal of all ingested foreign bodies; then, colonoscopic retrieval can be performed safely. REFERENCES 1. MCPHERSON RC, KARLAN M, WILLIAMS RD: Foreign body perforation of the intestinal tract. Am 1 Surg 94:564, 1957 2. ABEL RM, FISCHER jE, HENDREN WH: Penetration of the alimentary tract by a foreign body with migration to the liver. Arch Surg 102:227, 1971 3. BAIRD JM, SPENCE HM: Ingested foreign bodies migrating to the kidney from the gastrointestinal tract. 1 Urol 99:675, 1968 4. NELSON AM, FRANK HD, TAUBIN HL: Colovesical fistula secondary to foreign-body perforation of the sigmoid colon. Dis Colon Rectum 22:559, 1979 5. HAMBRICK E, RAO TR, LIM LT: jejunoaortic fistula from ingested seamstress needle. Arch Surg 114:732, 1979 6. JUSTINIANI FR, WIGODA L, ORTEGA RS: Duodenocaval fistula due to toothpick perforation. lAMA 227:788, 1974 7. ROGERS BHG, KOT C, MEIRI S, EpSTEIN M: Further studies on an over-tube used with the flexible fiberoptic esophagogastroduodenoscope to remove foreign bodies (abstract). Gastrointest Endosc 26:76, 1980 8. SORENSON RM, BOND JH )R: Colonoscopic removal of a foreign body from the cecum. Gastrointest Endosc 21:134, 1975 9. WOLF L, GERACI K: Colonoscopic removal of balloons from the bowel. Gastrointest Endosc 24:41, 1977 10. OEHLER JR, DENT TL, IBRAHIM MAH, GRACIE WA JR: Endoscopic identification and removal of an unusual symptomatic colonic foreign body. Dig Dis Sci 24:237, 1979
GASTROINTESTINAL ENDOSCOPY