- Email: [email protected]
Intrasplenic foreign body
lntrasplenic Foreign Body The Use of Induced Pneumoperitoneum for Diagnosis
Robert D. Gongaware,
MD, New York, New York
Judith S. Rose, MD, New York, New York Walter E. Berdon, MD, New York, New York Richard Weil, III, MD, New York, New York
Removal of intra-abdominal foreign bodies is aided by accurate localization of the object preoperatively. The present case report documents the successful preoperative localization of an intrasplenic needle discovered on chest roentgenogram of an asymptomatic five year old child. An extensive x-ray work-up had confirmed that the needle was not in the stomach, kidney, or colon. Diagnostic pneumoperitoneum was used preoperatively to prove the suspected intrasplenic location of the needle. This rarely used diagnostic procedure guided the decision to operate and aided in the selection of operative procedure.
There were no scars detectable over the left upper abdomen or thorax. An extensive radiographic work-up was then undertaken to localize the needle. Plain films of the abdomen in multiple views confirmed its location in the left upper quadrant. Barium enema examination revealed the needle to be above a normal splenic flexure. A limited upper gastrointestinal series using air contrast showed that the stomach was normal and that the needle was extragastric. (Figure 1.) Intravenous pyelography with nephrotomography showed the needle to be extrarenal. Fluoroscopy demonstrated that the needle moved with the diaphragm. In order to confirm the intrasplenic location, diagnostic
Case Report The patient (AS, =208-48-88), a five year old girl from Taiwan, had been followed at a public health clinic because of positive results on a tine test. Chest roentgenograms had given negative results until April 1971, when an x-ray film of the chest revealed a sewing needle in the left upper quadrant of the abdomen. The last chest x-ray film, taken five months previously, showed no abnormalities in the upper part of the abdomen. No history of foreign body ingestion could be elicited from the patient or the parents. There was no history of trauma. Physical examination revealed a healthy child with no palpable foreign body in the subcutaneous tissues over the left upper quadrant or the left lower thorax.
From the Departments of College of Physicians and Babtes Hospital. New York, Reprint requests should Street, New York, New York
694
Surgery and RadIology. Columbia University Surgeons; and the Surgical Service of the New York. be addressed to Dr Weil, 630 West 168th 10032.
Figure 1. The needle in the left upper quadrant overlies the spleen and is extrinsic to the barium-filled colon and the air-filled stomach.
The American
Journal of Surgery
lntrasplenic
Foreign Body
Figure 2. Erect abdominal film after the introduction of 300 ml of air shows that the needle and spleen have fallen away from the left diaphragm and left flank. Figure 3. Right decubitus abdominal film after the introduction of 300 ml of air shows that the needle and spleen have fallen away from the left diaphragm and felt flank.
pneumoperitoneum was carried out. Three hundred milliliters of air were introduced into the peritoneal cavity and radiographs in the erect and right lateral decubitus positions were obtained. (Figures 2 and 3.) The needle and spleen moved together on erect and decubitus views, demonstrating clearly the intrasplenic location of the foreign body. The patient underwent exploratory laparotomy on April 25, 1971. The lienocolic ligament was thickened, but the spleen was not adherent to any of the adjacent viscera,
diaphragm, or abdominal wall. Splenectomy was performed. The needle was entirely intrasplenic. Postoperative recovery was uneventful and the patient was discharged on the tenth postoperative day. Comments More than 80 per cent of ingested foreign bodies pass spontaneously [l-4]. Basing his thought on the work of Exner [5], Carp explained the safe passage of ingested sharp foreign bodies by the tendency of the gut to make the foreign body tumble until it was blunt end forward [2]. Several experiments were carried out in which needles were fed to animals. The vast majority were passed blunt end first. The average time taken for sharp objects to pass in his clinical series was seven days. Many authors have recommended that patients with foreign bodies seen on radiopaque studies be followed on an outpatient basis with serial roentgenograms. Surgical intervention has been recommended when the foreign body maintains the same relative position in the intestine for several days [3].
Volume 124. November 1972
foreign body should fail to pass and If an ingested penetrate the gut, peritonitis, abscess, granuloma, or hemorrhage may result [6]. There have been reports of foreign bodies penetrating the liver [A, kidney [8], and spleen [9]. The sites of gut perforation by ingested foreign bodies in seventy-one cases collected by Henderson and Gaston [1] were as follows: stomach, 37 per cent; duodenum, 14 per cent; small intestine, 17 per cent; cecum, 15 per cent; and colon 17 per cent [I]. Six of the colon perforations were via the splenic flexure. Macmanus’ series [4] of eighty-three cases included twelve cases of perforation of the colon. In our case we believe the needle perforated the splenic flexure and migrated into the spleen. In this child it was considered important to accurately define the location of the needle for two reasons: (1) If it were in the spleen, splenectomy should be recommended, in order to prevent splenic perforation and hemorrhage. (2) The needle might not be palpable at laparotomy. When simpler diagnostic methods failed to provide this information, diagnostic pneumoperitoneum was accomplished utilizing a technic which we have previously described [IO]. This single technic proved the intrasplenic location of the needle. Summary Diagnostic pneumoperitoneum successfully defined the intrasplenic location of a sharp intra-abdominal foreign body. On the basis of this information, splenectomy was recommended and performed.
695
Gongaware
et al
References 1. Henderson FF, Gaston EA: Ingested foreign body in the gastrointestinal tract. Arch Surg 36: 66, 1938. 2. Carp L: Foreign bodies in the intestine. Ann Surg 85: 575, 1927. 3. Stevenson EOS, Hastings N: Foreign bodies in the gastrointestinal tract. Amer Surg 34: 151, 1968. 4. Macmanus JE: Perforations of the intestine by ingested foreign bodies. Amer J Surg 53: 393, 1941. vor Verlet5. Exner A: Wie Schuetzt Sick der Verdauungstract zungen Durch Spitze Fremdoerper. Arch Ges Physiol. LXXXIX. 253, 1902. Quoted by Carp [Z).
696
6. Ginzberg L, Belier AJ: The clinical manifestations of nonmetallic perforating intestinal foreign bodies. Ann Surg 86: 928, 1927. 7. Abel RM, Fischer SF, Hendren WH: Penetration of the alimentary tract by a foreign body with migration to the liver. Arch Surg 102: 227, 1971. 8. Yue KP, Johnson HW: Foreign body in the kidney: transintestinal migration. J Ural 98: 172, 1967. 9. Shapiro AJ, Goldstein B: An unusual case of splenic rupture. J Amer Osteopath Ass 66: 651, 1967. 10. Baker DH et al: Use of pneumoperitoneum in differential diagnosis of paracardiac masses in children. Arch Surg 79: 63, 1959.
The American Journal of Surgery
Robert D. Gongaware,
MD, New York, New York
Judith S. Rose, MD, New York, New York Walter E. Berdon, MD, New York, New York Richard Weil, III, MD, New York, New York
Removal of intra-abdominal foreign bodies is aided by accurate localization of the object preoperatively. The present case report documents the successful preoperative localization of an intrasplenic needle discovered on chest roentgenogram of an asymptomatic five year old child. An extensive x-ray work-up had confirmed that the needle was not in the stomach, kidney, or colon. Diagnostic pneumoperitoneum was used preoperatively to prove the suspected intrasplenic location of the needle. This rarely used diagnostic procedure guided the decision to operate and aided in the selection of operative procedure.
There were no scars detectable over the left upper abdomen or thorax. An extensive radiographic work-up was then undertaken to localize the needle. Plain films of the abdomen in multiple views confirmed its location in the left upper quadrant. Barium enema examination revealed the needle to be above a normal splenic flexure. A limited upper gastrointestinal series using air contrast showed that the stomach was normal and that the needle was extragastric. (Figure 1.) Intravenous pyelography with nephrotomography showed the needle to be extrarenal. Fluoroscopy demonstrated that the needle moved with the diaphragm. In order to confirm the intrasplenic location, diagnostic
Case Report The patient (AS, =208-48-88), a five year old girl from Taiwan, had been followed at a public health clinic because of positive results on a tine test. Chest roentgenograms had given negative results until April 1971, when an x-ray film of the chest revealed a sewing needle in the left upper quadrant of the abdomen. The last chest x-ray film, taken five months previously, showed no abnormalities in the upper part of the abdomen. No history of foreign body ingestion could be elicited from the patient or the parents. There was no history of trauma. Physical examination revealed a healthy child with no palpable foreign body in the subcutaneous tissues over the left upper quadrant or the left lower thorax.
From the Departments of College of Physicians and Babtes Hospital. New York, Reprint requests should Street, New York, New York
694
Surgery and RadIology. Columbia University Surgeons; and the Surgical Service of the New York. be addressed to Dr Weil, 630 West 168th 10032.
Figure 1. The needle in the left upper quadrant overlies the spleen and is extrinsic to the barium-filled colon and the air-filled stomach.
The American
Journal of Surgery
lntrasplenic
Foreign Body
Figure 2. Erect abdominal film after the introduction of 300 ml of air shows that the needle and spleen have fallen away from the left diaphragm and left flank. Figure 3. Right decubitus abdominal film after the introduction of 300 ml of air shows that the needle and spleen have fallen away from the left diaphragm and felt flank.
pneumoperitoneum was carried out. Three hundred milliliters of air were introduced into the peritoneal cavity and radiographs in the erect and right lateral decubitus positions were obtained. (Figures 2 and 3.) The needle and spleen moved together on erect and decubitus views, demonstrating clearly the intrasplenic location of the foreign body. The patient underwent exploratory laparotomy on April 25, 1971. The lienocolic ligament was thickened, but the spleen was not adherent to any of the adjacent viscera,
diaphragm, or abdominal wall. Splenectomy was performed. The needle was entirely intrasplenic. Postoperative recovery was uneventful and the patient was discharged on the tenth postoperative day. Comments More than 80 per cent of ingested foreign bodies pass spontaneously [l-4]. Basing his thought on the work of Exner [5], Carp explained the safe passage of ingested sharp foreign bodies by the tendency of the gut to make the foreign body tumble until it was blunt end forward [2]. Several experiments were carried out in which needles were fed to animals. The vast majority were passed blunt end first. The average time taken for sharp objects to pass in his clinical series was seven days. Many authors have recommended that patients with foreign bodies seen on radiopaque studies be followed on an outpatient basis with serial roentgenograms. Surgical intervention has been recommended when the foreign body maintains the same relative position in the intestine for several days [3].
Volume 124. November 1972
foreign body should fail to pass and If an ingested penetrate the gut, peritonitis, abscess, granuloma, or hemorrhage may result [6]. There have been reports of foreign bodies penetrating the liver [A, kidney [8], and spleen [9]. The sites of gut perforation by ingested foreign bodies in seventy-one cases collected by Henderson and Gaston [1] were as follows: stomach, 37 per cent; duodenum, 14 per cent; small intestine, 17 per cent; cecum, 15 per cent; and colon 17 per cent [I]. Six of the colon perforations were via the splenic flexure. Macmanus’ series [4] of eighty-three cases included twelve cases of perforation of the colon. In our case we believe the needle perforated the splenic flexure and migrated into the spleen. In this child it was considered important to accurately define the location of the needle for two reasons: (1) If it were in the spleen, splenectomy should be recommended, in order to prevent splenic perforation and hemorrhage. (2) The needle might not be palpable at laparotomy. When simpler diagnostic methods failed to provide this information, diagnostic pneumoperitoneum was accomplished utilizing a technic which we have previously described [IO]. This single technic proved the intrasplenic location of the needle. Summary Diagnostic pneumoperitoneum successfully defined the intrasplenic location of a sharp intra-abdominal foreign body. On the basis of this information, splenectomy was recommended and performed.
695
Gongaware
et al
References 1. Henderson FF, Gaston EA: Ingested foreign body in the gastrointestinal tract. Arch Surg 36: 66, 1938. 2. Carp L: Foreign bodies in the intestine. Ann Surg 85: 575, 1927. 3. Stevenson EOS, Hastings N: Foreign bodies in the gastrointestinal tract. Amer Surg 34: 151, 1968. 4. Macmanus JE: Perforations of the intestine by ingested foreign bodies. Amer J Surg 53: 393, 1941. vor Verlet5. Exner A: Wie Schuetzt Sick der Verdauungstract zungen Durch Spitze Fremdoerper. Arch Ges Physiol. LXXXIX. 253, 1902. Quoted by Carp [Z).
696
6. Ginzberg L, Belier AJ: The clinical manifestations of nonmetallic perforating intestinal foreign bodies. Ann Surg 86: 928, 1927. 7. Abel RM, Fischer SF, Hendren WH: Penetration of the alimentary tract by a foreign body with migration to the liver. Arch Surg 102: 227, 1971. 8. Yue KP, Johnson HW: Foreign body in the kidney: transintestinal migration. J Ural 98: 172, 1967. 9. Shapiro AJ, Goldstein B: An unusual case of splenic rupture. J Amer Osteopath Ass 66: 651, 1967. 10. Baker DH et al: Use of pneumoperitoneum in differential diagnosis of paracardiac masses in children. Arch Surg 79: 63, 1959.
The American Journal of Surgery