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Foreign body perforation of the intestinal tract
Foreign
Body Perforation Intestinal Tract
of the
RICHARD C. MCPHERSON, M.D., MITCHELL KARLAN, M.D. AND ROGER D. WILLIAMS, M.D., Columbus, Ohio From tbe Department of Surgery, tbe Medical Center, tbe Obio State University, Columbus, Obio.
are reported to stress some of the interesting facets of foreign body perforation.
HE ingestion of foreign bodies is rareIy associated with intestina1 perforation even though the swaIIowed object is sharp. OnIy scattered case reports have foIIowed the ninetyfive cases of gastrointestinal perforation reported from a review of the Iiterature by [7] in 1941. AIthough IO to 20 per McManus cent of ingested foreign bodies wiI1 faiI to pass through the entire gastrointestina1 tract, Iess than I per cent cause perforation. The variety of clinica manifestations of intestina1 perforation coupIed with the usua1 absence of a history of foreign body ingestion makes this reIativeIy rare compIication diffIcuIt to diagnose but worthy of consideration in patients with unexplained peritonitis, intra-abdomina1 abscess or intestina1 obstruction. Six cases of foreign body perforation of the intestina tract have been seen at the University HospitaI during the past ten years. These cases
CASE REPORTS
T
IndividuaI case reports are repIaced by a chart which shows the pertinent findings in each case. (TabIe I.) Two features of foreign body perforation not previousIy reported or sufficientIy emphasized in the literature have been noted in our cases. These are the reIative frequency of associated chronic intestina1 obstruction and the use of dentures. The former may permit perforation at unusua1 sites while the Iatter probabIy is instrumenta in the unknowing ingestion of sharp foreign bodies. COMMENTS It is interesting that the probIem of foreign body ingestion first came into the foreground by the accidenta ingestion of a buckIe by Frederick WiIIiam I in his infancy [6]. That it passed through without significant compIica-
TABLE I INTESTINAL
Age (yr.) and Sex
History of Ingestion
PERFORATION
Duration of Symptoms (days)
BY
FOREIGN
BODIES
(SIX’i CASES) I
I
Foreign Body and Site of Perforation
I
I
80,F
.,_,.
Yes
..,...........
62,M............_...... 63,M...................
No No
62,M
No
..,...,.........
47,F .,..,........,...._. 75,F ,....._....._.......
No No
IO
14 4 3
I
* Inguinal hernia present. American
Journal
of Surgery,
Volume
94. October.
1957
564
I
Yes Yes Yes Yes Yes No
Straight pin, appendix Chicken bone, sigmoid Chicken bone, iIeum Toothpick, unknown (in omentum) Chicken bone, iIeum Chicken bone, sigmoid
3 28
Chronic Obstruction
Dentures
I
I
Yes Yes No* No* Yes Yes
Foreign’
Body
Perforation
tions was evidenced by his abiIity to produce his famous offspring, Frederick the Great. In 1602 the first gastrotomy for foreign body was reported by Mathis [2]. The patient was a professionat juggIer who had swallowed a knife. The first appendectomy was performed by CIaud Amyand in 1735 on an eIeven year oId bov who had a draining sinus of the right thigh which communicated with a right scrotaI hernia sac containing an appendix which had been perforatecl by a pin [I]. In view of the frequency of foreign body ingestion, it is remarkabIe how seIdom perforation of the gastrointestina1 tract occurs. Henderson [T], in 1938, reported 800 cases of foreign body ingestion seen at the Boston City Hospital in twenty-one years in which perforation occurred in only nine patients, representing a I per cent incidence. This incidence, of course, is even less when it is remembered that a great number of ingestions are not reported, either because symptoms are Iacking or the ingestion is unknown. Gross [_a]presented a series of 766 ingestions and stated that 25 per cent Iodged in the esophagus and gave symptoms of choking, dysphagia or discomfort. He stated that of those objects which reached the stomach, 93 per cent passed through the intestina1 tract without incident ancl that onIy 0.6 per cent caused perforation. McManus [7], in 1941, reported a review of the Iiterature which contained onIy ninety-five cases of gastrointestina1 perforation by foreign bodies. Fifty per cent of the patients were in the first three decades of Iife. MetaIIic objects such as pins and wire were responsible for 46 per cent of the perforations, and anima1 bones including those of fish, chicken and rabbits accounted for 46 per cent. Wood spIinters, toothpicks and pencils caused the remaining 9 per cent of the perforations. Certain factors pIay a prominent roIe in the etioIogy of ingestion of foreign objects. CareIessness is the most frequent vioIation, particuIarIy in chiIdren. Other causes include poor vision, mental infirmity, rapid eating, drug addiction, a dare and absent-mindedness. The use of dentures has not been adequately stressed as a cause of ingestion of sharp foreign bodies. Five of our six patients were edentuIous and wore dentures. The Iack of normaI paIata1 and gingiva1 sensation probabIy plays an important roIe, permitting the accidenta ingestion in these patients [y].
of Intestinal
Tract
The sites of perforation varied as have those reported in the Iiterature. The iIeoceca1 region was the most common area for perforation, a finding which is diff&It to explain on an anatomic basis. Perhaps either the iIeoceca1 vaIve offers some obstruction or the relative thinness of the bowel n-al1 in this area are factors; however, two of our perforations occurred in the sigmoid colon. It is conceivable that any obstruction to flow in the intestina1 tract would predispose to perforation by a sharp foreign body. In the older age group chronic obstruction due to a hernia, postoperative adhesions or atony of the bowel is more frequent and therefore could explain our correlation of perforation with both advanced age and obstruction. Four of our six patients did flave histories or operative evidence suggesting chronic obstruction prior to the estimated time of perforation. The other two patients with inguina1 hernias might be suspected of having obstruction, but no such history could be obtained. The diagnosis of foreign body perforation is eas? if a history of ingestion is avaiIabIe. The malority of patients who know they have swalIowed a sharp metalhc foreign body- usuaIIy seek medica advice. The diffIcuIty in diagnosis arises, however, in the patient who has unknowingIy swaIIowed a foreign object. If the object is radiopaque, the x-ray fiIm wiI1 aid in the diagnosis. In our cases, the diagnosis of perforation by non-opaque objects was onIy suspected in one case preoperativeIy. As reported in the literature, other diseases were simuIated, incIuding appendicitis, IocaIized abscess, diverticulitis and intestina1 obstruction. In addition, as pointed out by Ginzburg [?I, an abdomina1 waII abscess may deveIop in these patients due to adherence of the waII of the gut to the anterior abdomina1 wall before the actuaI perforation occurs. The treatment of foreign body perforation is directed to the comphcation which it has produced. Since a correct diagnosis is rareIy made before surgery, the principIes of surgery cannot be outIined. Great care shouId be given to the management of intestina1 obstruction and peritonitis if a Iow mortaIity is to be achieved. OnIy one of the six patients reported died postoperativeIy; this patient had extensive carcinomatosis and died of overwheIming infection. When surgery is performed for the Iysis of idiopathic adhesions, peritonitis or intra565
McPherson, abdomina1 considered
abscess, a foreign body and removed if present.
shouId
KarIan
and
WiIIiams REFERENCES
be I. FOWLER, R.
SUMMARY
Six cases of foreign body perforation of the intestinal tract have been presented and the Iiterature has been briefly reviewed. Although foreign body perforation is reIativeIy rare, it shouId be considered in atypica1 cases of peritonitis, intra-abdominal abscess or intestinaI obstruction. The use of dentures, which prevent pain on mastication of bones or toothpicks, probabIy pIays a major roIe in the ingestion of sharp foreign bodies in aduIts. Chronic partia1 intestina1 obstruction preceded the acute perforation in two-thirds of our cases and may be responsibIe in part for the perforation from ingested foreign bodies which might otherwise have passed uneventfuIIy.
566
2.
3.
4.
5.
6. 7.
H. Foreign body appendicitis, with especial reference to the domestic pin: an analysis of sixty-three cases. Ann. Surg., 56: 427-436, 1912. FRIEDENWALD,J. and ROSENTHAL.L. J. A statistical report of gastrotomies for removal of foreign bodies from the stomach. New York M. J., 78: IIo-122, 1903. GINZBURG, L. and BELLER, A. J. The cIinica1 manifestations of non-metaIlic perforating intestinal foreign bodies. Ann. Surg., 86: 928-939, 1927. GROSS, R. E. Foreign bodies in the alimentary tract. In: The Surgery of Infancy and Childhood, chapt. 18, pp. 246-252. PhiIadeIphia, 1953. W. B. Saunders Co. HENDERSON, F. F. and GASTON, E. A. Ingested foreign body in the gastrointestina1 tract. Arch. Surg., 36: 6695, x938. LAYTON, T. B. Historic foreign body. &it. M. J., I : 24, ‘930. MCMANUS, J. E. Perforation of the intestine by ingested foreign bodies. Am. J. Surg., 53: 393-402, 1941.
Body Perforation Intestinal Tract
of the
RICHARD C. MCPHERSON, M.D., MITCHELL KARLAN, M.D. AND ROGER D. WILLIAMS, M.D., Columbus, Ohio From tbe Department of Surgery, tbe Medical Center, tbe Obio State University, Columbus, Obio.
are reported to stress some of the interesting facets of foreign body perforation.
HE ingestion of foreign bodies is rareIy associated with intestina1 perforation even though the swaIIowed object is sharp. OnIy scattered case reports have foIIowed the ninetyfive cases of gastrointestinal perforation reported from a review of the Iiterature by [7] in 1941. AIthough IO to 20 per McManus cent of ingested foreign bodies wiI1 faiI to pass through the entire gastrointestina1 tract, Iess than I per cent cause perforation. The variety of clinica manifestations of intestina1 perforation coupIed with the usua1 absence of a history of foreign body ingestion makes this reIativeIy rare compIication diffIcuIt to diagnose but worthy of consideration in patients with unexplained peritonitis, intra-abdomina1 abscess or intestina1 obstruction. Six cases of foreign body perforation of the intestina tract have been seen at the University HospitaI during the past ten years. These cases
CASE REPORTS
T
IndividuaI case reports are repIaced by a chart which shows the pertinent findings in each case. (TabIe I.) Two features of foreign body perforation not previousIy reported or sufficientIy emphasized in the literature have been noted in our cases. These are the reIative frequency of associated chronic intestina1 obstruction and the use of dentures. The former may permit perforation at unusua1 sites while the Iatter probabIy is instrumenta in the unknowing ingestion of sharp foreign bodies. COMMENTS It is interesting that the probIem of foreign body ingestion first came into the foreground by the accidenta ingestion of a buckIe by Frederick WiIIiam I in his infancy [6]. That it passed through without significant compIica-
TABLE I INTESTINAL
Age (yr.) and Sex
History of Ingestion
PERFORATION
Duration of Symptoms (days)
BY
FOREIGN
BODIES
(SIX’i CASES) I
I
Foreign Body and Site of Perforation
I
I
80,F
.,_,.
Yes
..,...........
62,M............_...... 63,M...................
No No
62,M
No
..,...,.........
47,F .,..,........,...._. 75,F ,....._....._.......
No No
IO
14 4 3
I
* Inguinal hernia present. American
Journal
of Surgery,
Volume
94. October.
1957
564
I
Yes Yes Yes Yes Yes No
Straight pin, appendix Chicken bone, sigmoid Chicken bone, iIeum Toothpick, unknown (in omentum) Chicken bone, iIeum Chicken bone, sigmoid
3 28
Chronic Obstruction
Dentures
I
I
Yes Yes No* No* Yes Yes
Foreign’
Body
Perforation
tions was evidenced by his abiIity to produce his famous offspring, Frederick the Great. In 1602 the first gastrotomy for foreign body was reported by Mathis [2]. The patient was a professionat juggIer who had swallowed a knife. The first appendectomy was performed by CIaud Amyand in 1735 on an eIeven year oId bov who had a draining sinus of the right thigh which communicated with a right scrotaI hernia sac containing an appendix which had been perforatecl by a pin [I]. In view of the frequency of foreign body ingestion, it is remarkabIe how seIdom perforation of the gastrointestina1 tract occurs. Henderson [T], in 1938, reported 800 cases of foreign body ingestion seen at the Boston City Hospital in twenty-one years in which perforation occurred in only nine patients, representing a I per cent incidence. This incidence, of course, is even less when it is remembered that a great number of ingestions are not reported, either because symptoms are Iacking or the ingestion is unknown. Gross [_a]presented a series of 766 ingestions and stated that 25 per cent Iodged in the esophagus and gave symptoms of choking, dysphagia or discomfort. He stated that of those objects which reached the stomach, 93 per cent passed through the intestina1 tract without incident ancl that onIy 0.6 per cent caused perforation. McManus [7], in 1941, reported a review of the Iiterature which contained onIy ninety-five cases of gastrointestina1 perforation by foreign bodies. Fifty per cent of the patients were in the first three decades of Iife. MetaIIic objects such as pins and wire were responsible for 46 per cent of the perforations, and anima1 bones including those of fish, chicken and rabbits accounted for 46 per cent. Wood spIinters, toothpicks and pencils caused the remaining 9 per cent of the perforations. Certain factors pIay a prominent roIe in the etioIogy of ingestion of foreign objects. CareIessness is the most frequent vioIation, particuIarIy in chiIdren. Other causes include poor vision, mental infirmity, rapid eating, drug addiction, a dare and absent-mindedness. The use of dentures has not been adequately stressed as a cause of ingestion of sharp foreign bodies. Five of our six patients were edentuIous and wore dentures. The Iack of normaI paIata1 and gingiva1 sensation probabIy plays an important roIe, permitting the accidenta ingestion in these patients [y].
of Intestinal
Tract
The sites of perforation varied as have those reported in the Iiterature. The iIeoceca1 region was the most common area for perforation, a finding which is diff&It to explain on an anatomic basis. Perhaps either the iIeoceca1 vaIve offers some obstruction or the relative thinness of the bowel n-al1 in this area are factors; however, two of our perforations occurred in the sigmoid colon. It is conceivable that any obstruction to flow in the intestina1 tract would predispose to perforation by a sharp foreign body. In the older age group chronic obstruction due to a hernia, postoperative adhesions or atony of the bowel is more frequent and therefore could explain our correlation of perforation with both advanced age and obstruction. Four of our six patients did flave histories or operative evidence suggesting chronic obstruction prior to the estimated time of perforation. The other two patients with inguina1 hernias might be suspected of having obstruction, but no such history could be obtained. The diagnosis of foreign body perforation is eas? if a history of ingestion is avaiIabIe. The malority of patients who know they have swalIowed a sharp metalhc foreign body- usuaIIy seek medica advice. The diffIcuIty in diagnosis arises, however, in the patient who has unknowingIy swaIIowed a foreign object. If the object is radiopaque, the x-ray fiIm wiI1 aid in the diagnosis. In our cases, the diagnosis of perforation by non-opaque objects was onIy suspected in one case preoperativeIy. As reported in the literature, other diseases were simuIated, incIuding appendicitis, IocaIized abscess, diverticulitis and intestina1 obstruction. In addition, as pointed out by Ginzburg [?I, an abdomina1 waII abscess may deveIop in these patients due to adherence of the waII of the gut to the anterior abdomina1 wall before the actuaI perforation occurs. The treatment of foreign body perforation is directed to the comphcation which it has produced. Since a correct diagnosis is rareIy made before surgery, the principIes of surgery cannot be outIined. Great care shouId be given to the management of intestina1 obstruction and peritonitis if a Iow mortaIity is to be achieved. OnIy one of the six patients reported died postoperativeIy; this patient had extensive carcinomatosis and died of overwheIming infection. When surgery is performed for the Iysis of idiopathic adhesions, peritonitis or intra565
McPherson, abdomina1 considered
abscess, a foreign body and removed if present.
shouId
KarIan
and
WiIIiams REFERENCES
be I. FOWLER, R.
SUMMARY
Six cases of foreign body perforation of the intestinal tract have been presented and the Iiterature has been briefly reviewed. Although foreign body perforation is reIativeIy rare, it shouId be considered in atypica1 cases of peritonitis, intra-abdominal abscess or intestinaI obstruction. The use of dentures, which prevent pain on mastication of bones or toothpicks, probabIy pIays a major roIe in the ingestion of sharp foreign bodies in aduIts. Chronic partia1 intestina1 obstruction preceded the acute perforation in two-thirds of our cases and may be responsibIe in part for the perforation from ingested foreign bodies which might otherwise have passed uneventfuIIy.
566
2.
3.
4.
5.
6. 7.
H. Foreign body appendicitis, with especial reference to the domestic pin: an analysis of sixty-three cases. Ann. Surg., 56: 427-436, 1912. FRIEDENWALD,J. and ROSENTHAL.L. J. A statistical report of gastrotomies for removal of foreign bodies from the stomach. New York M. J., 78: IIo-122, 1903. GINZBURG, L. and BELLER, A. J. The cIinica1 manifestations of non-metaIlic perforating intestinal foreign bodies. Ann. Surg., 86: 928-939, 1927. GROSS, R. E. Foreign bodies in the alimentary tract. In: The Surgery of Infancy and Childhood, chapt. 18, pp. 246-252. PhiIadeIphia, 1953. W. B. Saunders Co. HENDERSON, F. F. and GASTON, E. A. Ingested foreign body in the gastrointestina1 tract. Arch. Surg., 36: 6695, x938. LAYTON, T. B. Historic foreign body. &it. M. J., I : 24, ‘930. MCMANUS, J. E. Perforation of the intestine by ingested foreign bodies. Am. J. Surg., 53: 393-402, 1941.