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Delayed appendicitis from an ingested foreign body
Delayed Appendicitis From an Ingested Foreign Body STEVEN M. GREEN, MD,*+ STEVEN P. SCHMIDT, MD,t STEVEN G. ROTHROCK, MD9 An unusual case of acute appendicitis induced by a metal drill bit that was inpested by a 27-year-old man 3 years before presentation is reported. This foreign body lodged in the patient’s appendix and developed a fecalith coating. When this fecallth coating enlarged enough to obstruct the appendiceal lumen, the patient presented with classic acute appendicitis. Foreign body-induced appendicitis Is reviewed.(Am J Emerg Med 1994; 12:53-56. Copyright Q 1994 by W.6. Saunders Company) “The a natural
appendix
is an eddy in the current
anatomical
i?s a predisposition
cesspool,
of the alimentav
and because
to the accumulation
of its location,
offilth.”
Kennedy,
canal. it inher-
1914’
Swallowed nondigestible objects tend to pass through the digestive tract without incident, and the vast majority of such cases do not require intervention.‘-4 Rarely, these foreign bodies drop into the appendix as they pass through the cecum. The appendix lies at the most inferior portion of the cecum. and passing objects may slip by their own weight into this cul-de-sac. Once in the appendix, it may be impossible for objects to re-enter the normal digestive path. A case that illustrates the morbidity that can result from an appendiceal foreign body is reported, and the related literature is reviewed. CASE REPORT A 27-year-old man in good health presented to the emergency department (ED) with a 24-hour history of abdominal pain. Initially. the pain had been diffuse, but then localized to the right lower quadrant. He described anorexia, nausea, and two episodes of emesis. His vital signs were as follows: temperature, 37.3”C; blood pressure, 117/66 mm Hg; pulse, 66 beats/mint and respiration, 16 breaths/min. Physical examination showed minimal bowel sounds and tenderness localized to the right lower quadrant at McBurney’s point. Periloneal signs were noted. The rest of the examination was unremarkable. Laboratory tests showed a white blood cell count of 18,700/mm3; urinalysis was free of white or red blood cells. A plain abdominal radiograph (Figure I) showed an apparent foreign body in the right lower abdomen. A lateral abdominal radiograph (Figure 2) confirmed that the foreign body was intra-abdominal, and that its location approximated that of the appendix. From the *Department of Emergency Medicine, Riverside General Hospital, Riverside; tDepartment of Surgery, Loma Linda University Medical Center, Loma Linda; *California Emergency Physicians Medical Group, Oakland, CA; and the QDepartment of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL. Manuscript received April 2, 1993; revision accepted May 2, 1993. Address reprint requests to Dr Green, Department of Emergency Medicine, Riverside General Hospital, 9851 Magnolia Ave, Riverside, CA 92503. Key Words: Appendicitis, appendicolith, fecalith, foreign body. Copyright 0 1993 by W.5. Saunders Company. 0735-6757/94/1201-0013$5.0010
The patient recalled that he had accidentally swallowed a small metallic bit from a power drill 3 years previously. He had been drilling on the ceiling and gazing upwards when, while holding a drill bit between his teeth, the bit slipped loose and was swallowed. He immediately consulted a physician, and a plain abdominal radiograph was performed. The physician informed him that the foreign body was in his stomach, and that it would pass without any further problem. After that initial evaluation, he had no further physician visits or repeat radiographs, and he could recall no remarkable symptoms from that time until the current presentation. The patient was taken to the operating room, and a transverse right lower quadrant incision was made. Cloudy fluid was noted on entering the peritoneal cavity, and a gangrenous appendix was encountered. A radiograph of the pathology specimen (Figure 3) showed that the foreign body was within the appendix. Dissection showed that a 4-mm layer of hard fecalith material coated the drill bit (Figures 4 and 5). The portion of the appendix proximal to the foreign body had minimal inflammation, whereas the distal segment was purulent and engorged. The patient did well postoperatively and was discharged 2 days later. DISCUSSION The primary inciting factor in the pathophysiology of appendicitis is felt to be obstruction of the lumen. Concretions of fecal material (fecaliths or appendicoliths) are commonly responsible, although adhesions and lymphoid hyperplasia have also been implicated.5 In highly unusual circumstances, foreign bodies can obstruct the appendiceal lumen in the same manner as appendicoliths and precipitate appendicitis.6 In the case presented, the appendicitis was almost certainly a complication of the ingested foreign body and not an incidental finding, because the inflammation was confined to the portion distal to the obstruction. Previous reports have described a variety of foreign bodies that were either found incidentally in appendices or were felt to be responsible for appendicitis (Table 1). Collins6 reported a landmark series of 7 1,000 appendix specimens obtained between 1923 and 1962 in which 44% overall contained fecaliths, 2% contained parasitic worms, and another 3% contained various foreign bodies. Foreign body-induced appendicitis was common before the 20th century. 6*‘6The first two recorded appendectomies, in 1735 and in 1759, were performed on patients with perforating metal sewing pins. 24 During this period,
the most com-
mon appendiceal foreign bodies that either induced appendicitis or were noted incidentally on autopsy were pins, needles, and lead shot.” In 1905 Rebentisch3’ reported the removal of an infected appendix containing 100 foreign bodies, including fruit seeds, stones, bone fragments, pieces of gallstones, and even part of a match! Another report” described an appendix containing numerous pieces of lead shot, animal hairs, 53
54
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FIGURE 1. A plain abdominal radiograph shows the presence of a metallic foreign body in the right lower abdomen.
FIGURE 2. A lateral abdominal radiograph confirms that the foreign body is within the abdomen.
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FIGURE 3. A radiograph of the surgical specimen before dissection confirms that the foreign body is within the appendix.
FIGURE 4. The pathology specimen (below the ruler) was dissected open, and the fecalith-coated foreign body (above the ruler) was found within the lumen. Note that the proximal portion of the specimen (on left) is minimally inflamed, whereas the distal portion (right) is gangrenous.
GREEN ET AL n FOREIGN
BODY-INDUCED
55
APPENDICITIS
TABLE1. Previously Foreign
Reported
lntraappendiceal
Bodies Metallic objects Bobby pins6 Bullets6-” Earring’* Endodontic file13 Fish hookI Intrauterine contraceptive deviceI Jackstone (child’s game)16 Key14 Lead shot and BB’s~,‘~.‘~-*’ Mercury, liquid6 Nails’ Needles6.‘6,22.*3 pins6.‘6,22.24-29
Safety pins6 Screws6,‘4 Tacks’ Plant materials Fruit seeds and pits6,‘6,30-32 Thorns” Wooden splinters and toothpick@ Animal or human materials Bones and portions of bone6,‘6,30 Eggshell fragments’4,20 GallstonesJo
FIGURE 5. The metallic foreign body (drill bit) is shown after removal of its fecalith coating. eggshell fragments, and four threadworms. Carey’H noted an appendix containing more than 500 pieces of lead shot. In 1898, Keen29 described a patient with a foreign bodyinduced periappendiceal abscess with a fistula extending into the bladder. In this case, the responsible pin migrated spontaneously through the listula into the urethra, through which it then passed. Reports of foreign body-induced appendicitis are extremely unusual in the current age, apparently a result of decreases in the frequency of hand-sewing and a diminished dependence on eating wild game. Elongated or sharp objects appear more likely to precipitate appendicitis by perforation. Several case reports have described foreign body-induced appendicitis developing 3 to 16 days after the ingestion of either pins or an endodontic file. 13.26.28 Thus if serial radiography demonstrates a sharp foreign body that appears unlikely to exit the appendix spontaneously, many authorities recommend that the patient undergo prophylactic appendectomy regardless of symptoms. 8.16.26 Blunt or round objects (eg. bullets, lead shot) appear less likely to cause perforation: however, they may develop a fecalith coating that can gradually enlarge over the ensuing years. If a size sufficient to obstruct the appendiceal lumen occurs, then appendicitis is the likely result. Accordingly, appendicitis from blunt foreign bodies typically occurs several years after ingestion, occasionally 10 years or more. 7,9,‘6.‘x Indeed, appendicitis may not develop at all. Reddy2’ described 62 Eskimos with lead shot in their appendices discovered during radiographic studies who were observed for up to I3 years. No cases of appendicitis occurred during this period. The likelihood of a patient with an appendiceal foreign body developing appendicitis is unknown. Ingestion of large amounts of seeds can rapidly induce appendicitis. Komarnitskiji and Koval’chuk3’ describe three youths who developed appendicitis 12 to 48 hours after eating large amounts of sunflower or grape seeds. All had appendices completely tilled with the foreign bodies. Foreign bodies have also been implicated in infections of the biliary tract3* and perforation of the small bowel’Y-4’ and of Meckcl’s diverticula.43-4h
Hair20.33
Parasitic worms6~20+’ Teeth and portions of teeth6,‘“,32,35 Miscellaneous Chewing gum6 Condom fragment6 Dental amalgam36 Fishing line6 Gambling dice16 Gastric tube tips6 Match fragment3’ Paraffin14 Plastic pieces6 Stones30 Thermometer fragmenti Thread’ Toothbrush bristles’6~32.37
Abdominal radiographs are of limited value when evaluating patients with suspected appendicitis, and may be more misleading than helpful in this setting.46‘49 In the current case, the foreign body was diagnosed preoperatively only as a result of plain abdominal radiography. However, if these films had not been ordered, the patient’s care would have been identical. and inevitably the foreign body would have been identified on pathological examination. Consequently, we do not believe that physicians should routinely obtain plain abdominal radiographs in patients with suspected appendicitis to search for the extremely rare radio-opaque foreign body. In patients with known ingestions of sharp foreign bodies, serial radiography is important to ensure that the objects do not lodge in the appendix. SUMMARY A case is reported of acute appendicitis induced by a metal drill bit that was ingested 3 years previously by a 27-year-old
56
AMERICAN
JOURNAL
OF EMERGENCY
man. Although ingested foreign bodies typically pass through the digestive tract without incident, physicians should be aware that in rare cases appendicitis may result from such episodes, and that the appearance of this condition may not occur until years after the ingestion. The authors thank Drs Christopher Hummel, Carmelina Tampus, and William Jones, for their valuable assistance and suggestions, and Drs Alix Vincent, Elena Spektor. Parvin Haghighat, and Humberto Ochoa for their expert translations. They also thank Dr Richard Guth for referring the patient to the ED.
REFERENCES 1. Kennedy JW: Foreign bodies in the appendix. New York Med J 1914;99:222-223 2. Caravati M, Bennett DL, McElwee NE: Pediatric coin ingestion: Prospective study on the utility of routine roentgenograms. Am J Dis Child 1989;143:549-551 3. Schunk JE, Corneli H, Bolte R: Pediatric coin ingestions: A prospective study of coin location and symptoms. Am J Dis Child ;989;143:546:548 4. Hodae D. Techlenbura F. Fleischer G: Coin inqestion: Does every chili need a radi;graph? Ann Emerg Med i985;14: 443-446 5. Walker AR, Segal I: What causes appendicitis? J Clin Gastroenterol 1990;12:127-129 6. Collins DC: 71,000 human appendix specimens: A final report, summarizing forty years’ study. Am J Proctol 1963;14: 365-381 7. Horby-Petersen J, Kristiansen T, Jelnes R: Acute appendicitis caused by metallic foreign body. Acta Chir Stand 1981;153 (1 l-12):697-698 8. Rydell WB Jr: Bullet appendicitis: A new form of lead poisoning. Rocky Mt Med J 1970;67(3):48-50 9. Price J, Dewar GA, Metreweli C: Airgun pellet appendicitis. Austr Radio1 1988;32(3):368-370 10. Sherlock DJ, Ambrose NS: An unusual case of appendicitis. J R Coll Surg Edinb 1985:30(5):318 11. Beccaria A, Troncone S: Acute appendicitis due to a foreign body. Minerva Gastroenterol 1965;11(2):90-92 12. Mourad K, Johanet H, Guibert L, et al: Appendicitis caused by gold. Presse Med 1990;19(34):1592 (letter) 13. Thomsen LC, Appleton SS, Engstrom HI: Appendicitis induced by an endodontic file. Gen Dent 1989;37(1):50-51 14. Franke A, Smolka G, Appelt E, et al: The appendix as a foreign body reservoir. Zentralbl Chir 1985;110(11):692-694 15. Rubinoff ML: IUD appendicitis. JAMA 1975;231(1):67-68 16. Balch CM, Silver D: Foreign bodies in the appendix. Report of eight cases and review of the literature. Arch Surg 1971;102(1):14-20 17. Durlach V, Lisovoski F. Gross A, et al: Appendicectomy in an unusual case of lead poisoning. Lancet 1986;1(8482):687-688 18. Carey LS: Lead shot appendicitis in northern native people. J Can Assoc Radio1 1977;28(3):171-174 19. Rosell J, Guerrero JA, Morales V, et al: Acute appendicitis after game ingestion. Rev Esp Enferm Apar Dig 1988;74(6):690691 (letter) 20. Nash WG: Foreign bodies in an appendix lying in a right inguinal hernia. Br Med J 1931;1:139 21. Reddy ER: Retained lead shot in the appendix. J Can Assot Radio1 1985;36(1):139 22. Deffrenne P, Pracros JP: Intra-appendicular foreign bodies. J Belge Radio1 1987;70(3):205-209 23. Wruhs 0: Unusual differential diagnosis of appendicitis in pregnancy. Zentralbl Chir 1966;91(52):1958-1961
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24. Creese PG: The first appendectomy. Surg Gynecol Obstet 1953;97:643-652 25. Wood MK, Harrison MR: ‘A-pin-dicitis’ and liver abscess. JAMA 1981;246(9):940 26. Stenstrom JD, Raine RJ: The nonmigrating pin. Can Med Assoc J 1978;118(10):1200 27. Duckler L: Foreign body producing appendicitis. Clin Pediatr 1976;15(4):383 28. Conforti FP, Smego DR, Kazarian KK: Halloween appendicitis: Pin perforation of the appendix. Conn Med 1987;51(8): 507 29. Keen WW: A case of appendicitis in which the appendix became permanently soldered to the bladder, like a third ureter, producing a urinary fecal fistula. Trans Am Surg Assoc 1898;16:243-252 30. Rebentisch: One hundred foreign bodies in an appendix. JAMA 1905;44:1815 31. Komarnitski ES, Koval’chuk AZ: A foreign body causing acute appendicitis. Klin Khir 1990;(4):72 32. Svitich IM: Foreign bodies of the appendix as a cause of acute appendicitis. Klin Khir 1983;(5):49 33. Stretch J, Bilous M, Cass D: Tricholuminal appendicitis: An unusual cause. Aust N Z J Surg 1986;56(9):731-732 34. Nadler S, Cappell MS, Bhatt 8, et al: Appendiceal infection by Entameoba histolytica and Strongyloides stercoralis presenting like acute appendicitis. Dig Dis Sci 1990;35:603-608 35. Benedikt VV, Kovalevski BA: Foreign body of the appendix as the cause of acute appendicitis. Klin Khir 1988;(4):64 36. Perkins CS: Amalgam appendicitis. Br Dent J 1991; 171(10):309 37. Fraser KD: A clinical trial to evaluate plaque removal with a double-headed toothbrush. Br Dent J 1991;171(7):195 38. Ban JL, Hirose FM, Benfield JR: Foreign bodies of the biliary tract: Report of two patients and a review of the literature. Ann Surg 1972;176(1):102-107 39. Cockerill FR, Wilson WR, Van Scoy RE: Traveling toothpicks. Mayo Clin Proc 1983;58(9):613-616 40. Schroder K: Cecum perforation by a foreign body with appendicitis symptoms. Zentralbl Chir 1968;93(17):626-630 41. Krasnozhon GI: Perforation of the ileum by a fish bone associated with acute phlegmonous appendicitis. Klin Khir 1988;(4):66 42. Kos R, Hangos G, Prekopp L: Foreign body perforation simulating acute appendicitis. Klin Med Osterr Z Wiss Prakt Med 1966;21(11):574-577 43. Gregorie HB Jr, Herbert KH: Foreign body perforation of Meckel’s diverticulum. Am Surg 1967:33(3):231-233 44. Kurzbauer R, Kurzbauer E, Kloza A, et al: Perforation of Meckel’s diverticulum by a foreign body. Pol Przegl Chir 1979; 51(7):683-684 45. Porfiri L, Capponi E: Pathology of Meckel’s diverticulum. Minerva Med 1972;63(9):505-516 46. Rothrock SG, Green SM. Harding M, et al: Plain abdominal radiography in the detection of acute medical and surgical disease in children: A retrospective analysis. Pediatr Emerg Care 1991;7:281-285 47. Rothrock SG, Green SM, Hummel CB: Plain abdominal radiography in the detection of major disease in children: A prospective analysis. Ann Emerg Med 1992;21:1423-1429 48. Campbell JP, Gunn AA: Plain abdominal radiographs and acute abdominal pain. Br J Surg 1988;75:554-556 49. Brewer RJ, Golden GT, Hitch DC, et al: Abdominal pain: An analysis of 1,000 consecutive cases in a university hospital emergency room. Am J Surg 1976;131:219-223
appendix
is an eddy in the current
anatomical
i?s a predisposition
cesspool,
of the alimentav
and because
to the accumulation
of its location,
offilth.”
Kennedy,
canal. it inher-
1914’
Swallowed nondigestible objects tend to pass through the digestive tract without incident, and the vast majority of such cases do not require intervention.‘-4 Rarely, these foreign bodies drop into the appendix as they pass through the cecum. The appendix lies at the most inferior portion of the cecum. and passing objects may slip by their own weight into this cul-de-sac. Once in the appendix, it may be impossible for objects to re-enter the normal digestive path. A case that illustrates the morbidity that can result from an appendiceal foreign body is reported, and the related literature is reviewed. CASE REPORT A 27-year-old man in good health presented to the emergency department (ED) with a 24-hour history of abdominal pain. Initially. the pain had been diffuse, but then localized to the right lower quadrant. He described anorexia, nausea, and two episodes of emesis. His vital signs were as follows: temperature, 37.3”C; blood pressure, 117/66 mm Hg; pulse, 66 beats/mint and respiration, 16 breaths/min. Physical examination showed minimal bowel sounds and tenderness localized to the right lower quadrant at McBurney’s point. Periloneal signs were noted. The rest of the examination was unremarkable. Laboratory tests showed a white blood cell count of 18,700/mm3; urinalysis was free of white or red blood cells. A plain abdominal radiograph (Figure I) showed an apparent foreign body in the right lower abdomen. A lateral abdominal radiograph (Figure 2) confirmed that the foreign body was intra-abdominal, and that its location approximated that of the appendix. From the *Department of Emergency Medicine, Riverside General Hospital, Riverside; tDepartment of Surgery, Loma Linda University Medical Center, Loma Linda; *California Emergency Physicians Medical Group, Oakland, CA; and the QDepartment of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL. Manuscript received April 2, 1993; revision accepted May 2, 1993. Address reprint requests to Dr Green, Department of Emergency Medicine, Riverside General Hospital, 9851 Magnolia Ave, Riverside, CA 92503. Key Words: Appendicitis, appendicolith, fecalith, foreign body. Copyright 0 1993 by W.5. Saunders Company. 0735-6757/94/1201-0013$5.0010
The patient recalled that he had accidentally swallowed a small metallic bit from a power drill 3 years previously. He had been drilling on the ceiling and gazing upwards when, while holding a drill bit between his teeth, the bit slipped loose and was swallowed. He immediately consulted a physician, and a plain abdominal radiograph was performed. The physician informed him that the foreign body was in his stomach, and that it would pass without any further problem. After that initial evaluation, he had no further physician visits or repeat radiographs, and he could recall no remarkable symptoms from that time until the current presentation. The patient was taken to the operating room, and a transverse right lower quadrant incision was made. Cloudy fluid was noted on entering the peritoneal cavity, and a gangrenous appendix was encountered. A radiograph of the pathology specimen (Figure 3) showed that the foreign body was within the appendix. Dissection showed that a 4-mm layer of hard fecalith material coated the drill bit (Figures 4 and 5). The portion of the appendix proximal to the foreign body had minimal inflammation, whereas the distal segment was purulent and engorged. The patient did well postoperatively and was discharged 2 days later. DISCUSSION The primary inciting factor in the pathophysiology of appendicitis is felt to be obstruction of the lumen. Concretions of fecal material (fecaliths or appendicoliths) are commonly responsible, although adhesions and lymphoid hyperplasia have also been implicated.5 In highly unusual circumstances, foreign bodies can obstruct the appendiceal lumen in the same manner as appendicoliths and precipitate appendicitis.6 In the case presented, the appendicitis was almost certainly a complication of the ingested foreign body and not an incidental finding, because the inflammation was confined to the portion distal to the obstruction. Previous reports have described a variety of foreign bodies that were either found incidentally in appendices or were felt to be responsible for appendicitis (Table 1). Collins6 reported a landmark series of 7 1,000 appendix specimens obtained between 1923 and 1962 in which 44% overall contained fecaliths, 2% contained parasitic worms, and another 3% contained various foreign bodies. Foreign body-induced appendicitis was common before the 20th century. 6*‘6The first two recorded appendectomies, in 1735 and in 1759, were performed on patients with perforating metal sewing pins. 24 During this period,
the most com-
mon appendiceal foreign bodies that either induced appendicitis or were noted incidentally on autopsy were pins, needles, and lead shot.” In 1905 Rebentisch3’ reported the removal of an infected appendix containing 100 foreign bodies, including fruit seeds, stones, bone fragments, pieces of gallstones, and even part of a match! Another report” described an appendix containing numerous pieces of lead shot, animal hairs, 53
54
AMERICAN
JOURNAL
OF EMERGENCY
FIGURE 1. A plain abdominal radiograph shows the presence of a metallic foreign body in the right lower abdomen.
FIGURE 2. A lateral abdominal radiograph confirms that the foreign body is within the abdomen.
MEDICINE
H Volume
12, Number
1 W January
1994
FIGURE 3. A radiograph of the surgical specimen before dissection confirms that the foreign body is within the appendix.
FIGURE 4. The pathology specimen (below the ruler) was dissected open, and the fecalith-coated foreign body (above the ruler) was found within the lumen. Note that the proximal portion of the specimen (on left) is minimally inflamed, whereas the distal portion (right) is gangrenous.
GREEN ET AL n FOREIGN
BODY-INDUCED
55
APPENDICITIS
TABLE1. Previously Foreign
Reported
lntraappendiceal
Bodies Metallic objects Bobby pins6 Bullets6-” Earring’* Endodontic file13 Fish hookI Intrauterine contraceptive deviceI Jackstone (child’s game)16 Key14 Lead shot and BB’s~,‘~.‘~-*’ Mercury, liquid6 Nails’ Needles6.‘6,22.*3 pins6.‘6,22.24-29
Safety pins6 Screws6,‘4 Tacks’ Plant materials Fruit seeds and pits6,‘6,30-32 Thorns” Wooden splinters and toothpick@ Animal or human materials Bones and portions of bone6,‘6,30 Eggshell fragments’4,20 GallstonesJo
FIGURE 5. The metallic foreign body (drill bit) is shown after removal of its fecalith coating. eggshell fragments, and four threadworms. Carey’H noted an appendix containing more than 500 pieces of lead shot. In 1898, Keen29 described a patient with a foreign bodyinduced periappendiceal abscess with a fistula extending into the bladder. In this case, the responsible pin migrated spontaneously through the listula into the urethra, through which it then passed. Reports of foreign body-induced appendicitis are extremely unusual in the current age, apparently a result of decreases in the frequency of hand-sewing and a diminished dependence on eating wild game. Elongated or sharp objects appear more likely to precipitate appendicitis by perforation. Several case reports have described foreign body-induced appendicitis developing 3 to 16 days after the ingestion of either pins or an endodontic file. 13.26.28 Thus if serial radiography demonstrates a sharp foreign body that appears unlikely to exit the appendix spontaneously, many authorities recommend that the patient undergo prophylactic appendectomy regardless of symptoms. 8.16.26 Blunt or round objects (eg. bullets, lead shot) appear less likely to cause perforation: however, they may develop a fecalith coating that can gradually enlarge over the ensuing years. If a size sufficient to obstruct the appendiceal lumen occurs, then appendicitis is the likely result. Accordingly, appendicitis from blunt foreign bodies typically occurs several years after ingestion, occasionally 10 years or more. 7,9,‘6.‘x Indeed, appendicitis may not develop at all. Reddy2’ described 62 Eskimos with lead shot in their appendices discovered during radiographic studies who were observed for up to I3 years. No cases of appendicitis occurred during this period. The likelihood of a patient with an appendiceal foreign body developing appendicitis is unknown. Ingestion of large amounts of seeds can rapidly induce appendicitis. Komarnitskiji and Koval’chuk3’ describe three youths who developed appendicitis 12 to 48 hours after eating large amounts of sunflower or grape seeds. All had appendices completely tilled with the foreign bodies. Foreign bodies have also been implicated in infections of the biliary tract3* and perforation of the small bowel’Y-4’ and of Meckcl’s diverticula.43-4h
Hair20.33
Parasitic worms6~20+’ Teeth and portions of teeth6,‘“,32,35 Miscellaneous Chewing gum6 Condom fragment6 Dental amalgam36 Fishing line6 Gambling dice16 Gastric tube tips6 Match fragment3’ Paraffin14 Plastic pieces6 Stones30 Thermometer fragmenti Thread’ Toothbrush bristles’6~32.37
Abdominal radiographs are of limited value when evaluating patients with suspected appendicitis, and may be more misleading than helpful in this setting.46‘49 In the current case, the foreign body was diagnosed preoperatively only as a result of plain abdominal radiography. However, if these films had not been ordered, the patient’s care would have been identical. and inevitably the foreign body would have been identified on pathological examination. Consequently, we do not believe that physicians should routinely obtain plain abdominal radiographs in patients with suspected appendicitis to search for the extremely rare radio-opaque foreign body. In patients with known ingestions of sharp foreign bodies, serial radiography is important to ensure that the objects do not lodge in the appendix. SUMMARY A case is reported of acute appendicitis induced by a metal drill bit that was ingested 3 years previously by a 27-year-old
56
AMERICAN
JOURNAL
OF EMERGENCY
man. Although ingested foreign bodies typically pass through the digestive tract without incident, physicians should be aware that in rare cases appendicitis may result from such episodes, and that the appearance of this condition may not occur until years after the ingestion. The authors thank Drs Christopher Hummel, Carmelina Tampus, and William Jones, for their valuable assistance and suggestions, and Drs Alix Vincent, Elena Spektor. Parvin Haghighat, and Humberto Ochoa for their expert translations. They also thank Dr Richard Guth for referring the patient to the ED.
REFERENCES 1. Kennedy JW: Foreign bodies in the appendix. New York Med J 1914;99:222-223 2. Caravati M, Bennett DL, McElwee NE: Pediatric coin ingestion: Prospective study on the utility of routine roentgenograms. Am J Dis Child 1989;143:549-551 3. Schunk JE, Corneli H, Bolte R: Pediatric coin ingestions: A prospective study of coin location and symptoms. Am J Dis Child ;989;143:546:548 4. Hodae D. Techlenbura F. Fleischer G: Coin inqestion: Does every chili need a radi;graph? Ann Emerg Med i985;14: 443-446 5. Walker AR, Segal I: What causes appendicitis? J Clin Gastroenterol 1990;12:127-129 6. Collins DC: 71,000 human appendix specimens: A final report, summarizing forty years’ study. Am J Proctol 1963;14: 365-381 7. Horby-Petersen J, Kristiansen T, Jelnes R: Acute appendicitis caused by metallic foreign body. Acta Chir Stand 1981;153 (1 l-12):697-698 8. Rydell WB Jr: Bullet appendicitis: A new form of lead poisoning. Rocky Mt Med J 1970;67(3):48-50 9. Price J, Dewar GA, Metreweli C: Airgun pellet appendicitis. Austr Radio1 1988;32(3):368-370 10. Sherlock DJ, Ambrose NS: An unusual case of appendicitis. J R Coll Surg Edinb 1985:30(5):318 11. Beccaria A, Troncone S: Acute appendicitis due to a foreign body. Minerva Gastroenterol 1965;11(2):90-92 12. Mourad K, Johanet H, Guibert L, et al: Appendicitis caused by gold. Presse Med 1990;19(34):1592 (letter) 13. Thomsen LC, Appleton SS, Engstrom HI: Appendicitis induced by an endodontic file. Gen Dent 1989;37(1):50-51 14. Franke A, Smolka G, Appelt E, et al: The appendix as a foreign body reservoir. Zentralbl Chir 1985;110(11):692-694 15. Rubinoff ML: IUD appendicitis. JAMA 1975;231(1):67-68 16. Balch CM, Silver D: Foreign bodies in the appendix. Report of eight cases and review of the literature. Arch Surg 1971;102(1):14-20 17. Durlach V, Lisovoski F. Gross A, et al: Appendicectomy in an unusual case of lead poisoning. Lancet 1986;1(8482):687-688 18. Carey LS: Lead shot appendicitis in northern native people. J Can Assoc Radio1 1977;28(3):171-174 19. Rosell J, Guerrero JA, Morales V, et al: Acute appendicitis after game ingestion. Rev Esp Enferm Apar Dig 1988;74(6):690691 (letter) 20. Nash WG: Foreign bodies in an appendix lying in a right inguinal hernia. Br Med J 1931;1:139 21. Reddy ER: Retained lead shot in the appendix. J Can Assot Radio1 1985;36(1):139 22. Deffrenne P, Pracros JP: Intra-appendicular foreign bodies. J Belge Radio1 1987;70(3):205-209 23. Wruhs 0: Unusual differential diagnosis of appendicitis in pregnancy. Zentralbl Chir 1966;91(52):1958-1961
MEDICINE
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12, Number
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