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Duodenal perforation due to an ingested lollipop stick in a 7-year-old boy
Journal Pre-proof Duodenal perforation due to an ingested lollipop stick in a 7-year-old boy Jinyoung Park PII:
S2213-5766(19)30284-2
DOI:
https://doi.org/10.1016/j.epsc.2019.101325
Reference:
EPSC 101325
To appear in:
Journal of Pediatric Surgery Case Reports
Received Date: 20 September 2019 Revised Date:
11 October 2019
Accepted Date: 14 October 2019
Please cite this article as: Park J, Duodenal perforation due to an ingested lollipop stick in a 7-year-old boy, Journal of Pediatric Surgery Case Reports (2019), doi: https://doi.org/10.1016/j.epsc.2019.101325. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
Duodenal perforation due to an ingested lollipop stick in a 7-year-old boy
Jinyoung Park, M.D
Department of Pediatric Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
Correspondence: Jinyoung Park, M.D Address: Department of Pediatric Surgery, Kyungpook National University Hospital, 50 Samduk-Dong, 2-Ga, Jung-Gu, Daegu, 700-721, South Korea TEL: 82-53-420-5612 FAX: 82-53-421-0510 E-mail: [email protected]
ABSTRACT Ingestion of a foreign body is a frequently encountered clinical problem in children. Most swallowed foreign bodies are spontaneously excreted in the feces without intervention. Fewer than 1% of ingested foreign bodies lead to bleeding, obstruction or perforation of the gastrointestinal tract, mandating surgical intervention. This study describes a 7-year-old boy who presented with duodenal perforation caused by ingestion of a lollipop stick and who was successfully managed by surgery. KEY WORDS: Foreign body, Lollipop stick, Duodenal perforation
INTRODUCTION Children have a natural tendency to explore objects with their mouths, frequently leading to ingestion of foreign bodies (1-5). Most ingested foreign bodies pass spontaneously through the gastrointestinal tract (6-8). Fewer than 1% of ingested foreign bodies lead to bleeding, obstruction or perforation of the gastrointestinal tract, mandating surgical intervention (9-10). The most common sites of gastrointestinal perforation by foreign bodies are the ileocecum and rectosigmoid colon. Foreign body perforation of the duodenum is less common (2). This study describes a 7-year-old boy who presented with duodenal perforation caused by ingestion of a lollipop stick and who was successfully managed by surgery.
CASE REPORT A 7-year-old boy with no previous medical history presented to the emergency department of our hospital with upper abdominal pain that started 3 days earlier. Physical examination
revealed a mild tenderness in the epigastrium, without rebound tenderness in the upper abdomen. His vital signs included a blood pressure of 130/96 mmHg; a heart rate of 103 beats per minute; a respiratory rate of 20 breaths per minute; and a body temperature of 36.5ºC. Laboratory findings were within normal limits, except for mild increases in Creactive protein concentration (4.25 mg/dL; reference range, < 0.3 mg/dL) and erythrocyte sedimentation rate (72 mm/hr; reference range, 0–15 mm/hr). Plain radiography of the abdomen did not reveal any abnormal findings. Abdominal ultrasonography showed an echogenic tubular structure in the duodenum with the possibility of duodenal perforation (Fig 1). An abdominal computed tomography scan also showed a linear tubular foreign body about 6 cm in length situated vertically in the duodenum (Fig 2). The patient was unaware of ingesting the foreign body. Emergency esophagogastroduodenoscopy to identify the foreign body showed a plastic stick impacted into the duodenal mucosa at the third portion of the duodenum with suspected duodenal perforation (Fig 3). Exploratory surgery showed a plastic stick penetrating into the inferior wall of the third portion of the duodenum, with part of the stick impacting the adjacent retroperitoneal space (Fig 4). A 7-cm-long plastic stick was removed through the duodenal perforation site, which was subsequently debrided and closed primarily with interrupted 4-0 silk sutures (Fig 5). Upon questioning, the patient’s mother recalled that he had fallen asleep with a lollipop stick in his mouth. The patient’s postoperative course was uneventful, and he was discharged from the hospital 9 days after surgery. He has remained asymptomatic at subsequent follow-up 8 months after discharge.
DISCUSSION Elderly and mentally ill patients, as well as children, unintentionally ingest foreign bodies. Children have a natural tendency to explore items with their mouths, which can frequently
result in the swallowing of foreign materials (1, 2). Foreign body ingestion usually occurs in children aged 6 months to 3 years (2). Commonly ingested materials include coins, fish and chicken bones, toy parts, jewelry, button-type batteries, and magnets (6, 8). Although diagnosing foreign body ingestion requires determining a patient’s medical history of swallowing foreign bodies, children frequently do not remember swallowing foreign objects. This complicates the diagnosis of foreign body ingestion, as do its various clinical manifestations and poor preoperative visualization on plain radiography. Although most ingested foreign bodies pass spontaneously and uneventfully through the gastrointestinal tract within 1 week, about 1% of patients experience complications, such as gastrointestinal obstruction or perforation (1-8). Ingested foreign bodies can have anatomic impact on areas of angulation, including the hypopharynx, esophagus, pylorus, C-loop of duodenum, duodenojejunal junction and ileocecal valve (4, 5). Ingestion of long, sharp, and rigid foreign bodies is associated with increased risks of complications, such as impaction, bleeding and perforation. The clinical presentation of foreign body ingestion is dependent on the location of the impaction or perforation. Manifestations of gastrointestinal perforation include localized peritonitis, formation of an abscess or inflammatory mass, fistula, hemorrhage, and obstruction. Linear foreign bodies may migrate to adjacent organs, such as the liver and kidneys, cause fistulae, abscesses and/or septicemia (7). Gradual erosion of the walls of the gastrointestinal tract by foreign bodies may be initially asymptomatic, later progressing to chronic inflammatory processes (9). Moreover, ingestion of these foreign bodies may be found incidentally after months or years (9). The most common sites of gastrointestinal perforation by foreign bodies are the ileocecum and rectosigmoid colon (2). Foreign body perforation of the duodenum is much less common.
Foreign body perforation by fish and chicken bone fragments, toothpicks, plastic bread bag clips, or cocktail sticks is difficult to diagnose. Non-radio-opaque foreign materials do not appear on plain radiographs, making them difficult to detect prior to surgery. Although more radio-opaque foreign bodies can be detected on abdominal radiographs, the presence of these materials, as well as associated complications, can be detected by abdominal ultrasonography and computed tomography scans (2, 10). Gastrointestinal perforations by foreign bodies are rarely accompanied by free air in the abdominal cavity. If foreign material is entrapped or impacted in the intestinal wall and the wall is eroded progressively, the perforation site may be sealed by fibrin, surrounding omentum or an adjacent bowel loop, limiting the leakage of intraluminal air into the peritoneal cavity (6). Perforation of the duodenum may not result in free intraperitoneal perforation due to the retroperitoneal location of certain segments of the duodenum. Symptoms in these patients may be non-specific, delaying diagnosis (6). The duodenum is relatively immobile, rigid and sharply angulated and is located in the retroperitoneum, resulting in the easy entrapment of long and sharp ended objects (11). Passing objects longer than 6–10 cm through the duodenum is difficult, requiring surgical intervention (2, 11). Although uncommon, gastrointestinal perforation by an ingested foreign body may be potentially life threatening. The findings in this patient suggest the need for awareness of the potential risk of gastrointestinal perforation by lollipop sticks.
Patient consent: Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identification of the patient.
Funding: No funding or grant support.
Authorship: All authors attest that they meet the current ICMJE criteria for Authorship.
Conflict of interest: The following authors have no financial disclosures: (Park J).
REFERENCES 1. Hartin CW Jr, Caty MG, Bass KD. Laparoscopy for perforated Richter hernia with incarcerated foreign body. J Pediatr Surg. 2011;46:1449-51 2. Kim MJ, Seo JM, Lee Y, Lee YM, Choe YH. An unusual cause of duodenal perforation due to a lollipop stick. Korean J Pediatr. 2013;56:182-5 3. Cho EA, Lee du H, Hong HJ, Park CH, Park SY, Kim HS, Choi SK, Rew JS. An unusual case of duodenal perforation caused by a lollipop stick: a case report. Clin Endosc. 2014;47:188-91 4. Boškoski I, Tringali A, Landi R, Familiari P, Contini AC, Pintus C, Costamagna G. Endoscopic retrieval of a duodenal perforating teaspoon. World J Gastrointest Endosc. 2013;5:186-8 5. Ragazzi M, Delcò F, Rodoni-Cassis P, Brenna M, Lavanchy L, Bianchetti MG. Toothpick ingestion causing duodenal perforation. Pediatr Emerg Care. 2010;26:506-7 6. Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, Wong WK. Perforation of the
gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg. 2006;30:372-7 7. Newman B. Duodenorenal fistula. Pediatr Radiol. 2004;34:343-7 8. Jayachandra S, Eslick GD. A systematic review of paediatric foreign body ingestion: presentation, complications, and management. Int J Pediatr Otorhinolaryngol. 2013;77:311-7 9. Kuzmich S, Burke CJ, Harvey CJ, Kuzmich T, Andrews J, Reading N, Pathak S, Patel N. Perforation of gastrointestinal tract by poorly conspicuous ingested foreign bodies: radiological diagnosis. Br J Radiol. 2015;88(1050):20150086 10. Coulier B, Tancredi MH, Ramboux A. Spiral CT and multidetector-row CT diagnosis of perforation of the small intestine caused by ingested foreign bodies. Eur Radiol. 2004;14:1918-25 11. Chao HH, Chao TC. Perforation of the duodenum by an ingested toothbrush. World J Gastroenterol. 2008;14:4410-2
FIGURE LEGENDS Figure 1. Abdominal ultrasonography showing an echogenic tubular structure in the third portion of the duodenum with the possibility of duodenal perforation.
Figure 2. Abdominal computed tomography scan showing a linear tubular foreign body about 6 cm in length situated vertically in the duodenum (white arrow).
Figure 3. Esophagogastroduodenoscopy showing a plastic stick impacted into the duodenal mucosa at the third portion of the duodenum with suspected duodenal perforation.
Figure 4. Operative view showing a plastic stick penetrating into the inferior wall of the third portion of the duodenum. Part of the plastic stick was also impacted into the adjacent retroperitoneal space.
Figure 5. Removal of the 7-cm long lollipop stick.
Highlights 1. Fewer than 1 % of ingested foreign bodies lead to bleeding, obstruction or perforation of the gastrointestinal tract, mandating surgical intervention.
2. Foreign body perforation of the duodenum is less common.
3. We suggest the need for awareness of the potential risk of gastrointestinal perforation by lollipop stick.
Conflict of Interest: The authors declare that we have no conflict of interest.
S2213-5766(19)30284-2
DOI:
https://doi.org/10.1016/j.epsc.2019.101325
Reference:
EPSC 101325
To appear in:
Journal of Pediatric Surgery Case Reports
Received Date: 20 September 2019 Revised Date:
11 October 2019
Accepted Date: 14 October 2019
Please cite this article as: Park J, Duodenal perforation due to an ingested lollipop stick in a 7-year-old boy, Journal of Pediatric Surgery Case Reports (2019), doi: https://doi.org/10.1016/j.epsc.2019.101325. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
Duodenal perforation due to an ingested lollipop stick in a 7-year-old boy
Jinyoung Park, M.D
Department of Pediatric Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
Correspondence: Jinyoung Park, M.D Address: Department of Pediatric Surgery, Kyungpook National University Hospital, 50 Samduk-Dong, 2-Ga, Jung-Gu, Daegu, 700-721, South Korea TEL: 82-53-420-5612 FAX: 82-53-421-0510 E-mail: [email protected]
ABSTRACT Ingestion of a foreign body is a frequently encountered clinical problem in children. Most swallowed foreign bodies are spontaneously excreted in the feces without intervention. Fewer than 1% of ingested foreign bodies lead to bleeding, obstruction or perforation of the gastrointestinal tract, mandating surgical intervention. This study describes a 7-year-old boy who presented with duodenal perforation caused by ingestion of a lollipop stick and who was successfully managed by surgery. KEY WORDS: Foreign body, Lollipop stick, Duodenal perforation
INTRODUCTION Children have a natural tendency to explore objects with their mouths, frequently leading to ingestion of foreign bodies (1-5). Most ingested foreign bodies pass spontaneously through the gastrointestinal tract (6-8). Fewer than 1% of ingested foreign bodies lead to bleeding, obstruction or perforation of the gastrointestinal tract, mandating surgical intervention (9-10). The most common sites of gastrointestinal perforation by foreign bodies are the ileocecum and rectosigmoid colon. Foreign body perforation of the duodenum is less common (2). This study describes a 7-year-old boy who presented with duodenal perforation caused by ingestion of a lollipop stick and who was successfully managed by surgery.
CASE REPORT A 7-year-old boy with no previous medical history presented to the emergency department of our hospital with upper abdominal pain that started 3 days earlier. Physical examination
revealed a mild tenderness in the epigastrium, without rebound tenderness in the upper abdomen. His vital signs included a blood pressure of 130/96 mmHg; a heart rate of 103 beats per minute; a respiratory rate of 20 breaths per minute; and a body temperature of 36.5ºC. Laboratory findings were within normal limits, except for mild increases in Creactive protein concentration (4.25 mg/dL; reference range, < 0.3 mg/dL) and erythrocyte sedimentation rate (72 mm/hr; reference range, 0–15 mm/hr). Plain radiography of the abdomen did not reveal any abnormal findings. Abdominal ultrasonography showed an echogenic tubular structure in the duodenum with the possibility of duodenal perforation (Fig 1). An abdominal computed tomography scan also showed a linear tubular foreign body about 6 cm in length situated vertically in the duodenum (Fig 2). The patient was unaware of ingesting the foreign body. Emergency esophagogastroduodenoscopy to identify the foreign body showed a plastic stick impacted into the duodenal mucosa at the third portion of the duodenum with suspected duodenal perforation (Fig 3). Exploratory surgery showed a plastic stick penetrating into the inferior wall of the third portion of the duodenum, with part of the stick impacting the adjacent retroperitoneal space (Fig 4). A 7-cm-long plastic stick was removed through the duodenal perforation site, which was subsequently debrided and closed primarily with interrupted 4-0 silk sutures (Fig 5). Upon questioning, the patient’s mother recalled that he had fallen asleep with a lollipop stick in his mouth. The patient’s postoperative course was uneventful, and he was discharged from the hospital 9 days after surgery. He has remained asymptomatic at subsequent follow-up 8 months after discharge.
DISCUSSION Elderly and mentally ill patients, as well as children, unintentionally ingest foreign bodies. Children have a natural tendency to explore items with their mouths, which can frequently
result in the swallowing of foreign materials (1, 2). Foreign body ingestion usually occurs in children aged 6 months to 3 years (2). Commonly ingested materials include coins, fish and chicken bones, toy parts, jewelry, button-type batteries, and magnets (6, 8). Although diagnosing foreign body ingestion requires determining a patient’s medical history of swallowing foreign bodies, children frequently do not remember swallowing foreign objects. This complicates the diagnosis of foreign body ingestion, as do its various clinical manifestations and poor preoperative visualization on plain radiography. Although most ingested foreign bodies pass spontaneously and uneventfully through the gastrointestinal tract within 1 week, about 1% of patients experience complications, such as gastrointestinal obstruction or perforation (1-8). Ingested foreign bodies can have anatomic impact on areas of angulation, including the hypopharynx, esophagus, pylorus, C-loop of duodenum, duodenojejunal junction and ileocecal valve (4, 5). Ingestion of long, sharp, and rigid foreign bodies is associated with increased risks of complications, such as impaction, bleeding and perforation. The clinical presentation of foreign body ingestion is dependent on the location of the impaction or perforation. Manifestations of gastrointestinal perforation include localized peritonitis, formation of an abscess or inflammatory mass, fistula, hemorrhage, and obstruction. Linear foreign bodies may migrate to adjacent organs, such as the liver and kidneys, cause fistulae, abscesses and/or septicemia (7). Gradual erosion of the walls of the gastrointestinal tract by foreign bodies may be initially asymptomatic, later progressing to chronic inflammatory processes (9). Moreover, ingestion of these foreign bodies may be found incidentally after months or years (9). The most common sites of gastrointestinal perforation by foreign bodies are the ileocecum and rectosigmoid colon (2). Foreign body perforation of the duodenum is much less common.
Foreign body perforation by fish and chicken bone fragments, toothpicks, plastic bread bag clips, or cocktail sticks is difficult to diagnose. Non-radio-opaque foreign materials do not appear on plain radiographs, making them difficult to detect prior to surgery. Although more radio-opaque foreign bodies can be detected on abdominal radiographs, the presence of these materials, as well as associated complications, can be detected by abdominal ultrasonography and computed tomography scans (2, 10). Gastrointestinal perforations by foreign bodies are rarely accompanied by free air in the abdominal cavity. If foreign material is entrapped or impacted in the intestinal wall and the wall is eroded progressively, the perforation site may be sealed by fibrin, surrounding omentum or an adjacent bowel loop, limiting the leakage of intraluminal air into the peritoneal cavity (6). Perforation of the duodenum may not result in free intraperitoneal perforation due to the retroperitoneal location of certain segments of the duodenum. Symptoms in these patients may be non-specific, delaying diagnosis (6). The duodenum is relatively immobile, rigid and sharply angulated and is located in the retroperitoneum, resulting in the easy entrapment of long and sharp ended objects (11). Passing objects longer than 6–10 cm through the duodenum is difficult, requiring surgical intervention (2, 11). Although uncommon, gastrointestinal perforation by an ingested foreign body may be potentially life threatening. The findings in this patient suggest the need for awareness of the potential risk of gastrointestinal perforation by lollipop sticks.
Patient consent: Consent to publish the case report was not obtained. This report does not contain any personal information that could lead to the identification of the patient.
Funding: No funding or grant support.
Authorship: All authors attest that they meet the current ICMJE criteria for Authorship.
Conflict of interest: The following authors have no financial disclosures: (Park J).
REFERENCES 1. Hartin CW Jr, Caty MG, Bass KD. Laparoscopy for perforated Richter hernia with incarcerated foreign body. J Pediatr Surg. 2011;46:1449-51 2. Kim MJ, Seo JM, Lee Y, Lee YM, Choe YH. An unusual cause of duodenal perforation due to a lollipop stick. Korean J Pediatr. 2013;56:182-5 3. Cho EA, Lee du H, Hong HJ, Park CH, Park SY, Kim HS, Choi SK, Rew JS. An unusual case of duodenal perforation caused by a lollipop stick: a case report. Clin Endosc. 2014;47:188-91 4. Boškoski I, Tringali A, Landi R, Familiari P, Contini AC, Pintus C, Costamagna G. Endoscopic retrieval of a duodenal perforating teaspoon. World J Gastrointest Endosc. 2013;5:186-8 5. Ragazzi M, Delcò F, Rodoni-Cassis P, Brenna M, Lavanchy L, Bianchetti MG. Toothpick ingestion causing duodenal perforation. Pediatr Emerg Care. 2010;26:506-7 6. Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, Wong WK. Perforation of the
gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg. 2006;30:372-7 7. Newman B. Duodenorenal fistula. Pediatr Radiol. 2004;34:343-7 8. Jayachandra S, Eslick GD. A systematic review of paediatric foreign body ingestion: presentation, complications, and management. Int J Pediatr Otorhinolaryngol. 2013;77:311-7 9. Kuzmich S, Burke CJ, Harvey CJ, Kuzmich T, Andrews J, Reading N, Pathak S, Patel N. Perforation of gastrointestinal tract by poorly conspicuous ingested foreign bodies: radiological diagnosis. Br J Radiol. 2015;88(1050):20150086 10. Coulier B, Tancredi MH, Ramboux A. Spiral CT and multidetector-row CT diagnosis of perforation of the small intestine caused by ingested foreign bodies. Eur Radiol. 2004;14:1918-25 11. Chao HH, Chao TC. Perforation of the duodenum by an ingested toothbrush. World J Gastroenterol. 2008;14:4410-2
FIGURE LEGENDS Figure 1. Abdominal ultrasonography showing an echogenic tubular structure in the third portion of the duodenum with the possibility of duodenal perforation.
Figure 2. Abdominal computed tomography scan showing a linear tubular foreign body about 6 cm in length situated vertically in the duodenum (white arrow).
Figure 3. Esophagogastroduodenoscopy showing a plastic stick impacted into the duodenal mucosa at the third portion of the duodenum with suspected duodenal perforation.
Figure 4. Operative view showing a plastic stick penetrating into the inferior wall of the third portion of the duodenum. Part of the plastic stick was also impacted into the adjacent retroperitoneal space.
Figure 5. Removal of the 7-cm long lollipop stick.
Highlights 1. Fewer than 1 % of ingested foreign bodies lead to bleeding, obstruction or perforation of the gastrointestinal tract, mandating surgical intervention.
2. Foreign body perforation of the duodenum is less common.
3. We suggest the need for awareness of the potential risk of gastrointestinal perforation by lollipop stick.
Conflict of Interest: The authors declare that we have no conflict of interest.