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Foreign body ingestion--glass in colon and rectum--a case report and literature review/Progutana strana tela--staklo u kolonu i rektumu--prikaz slucaja I pregled literature.

Introduction

Ingestion of a foreign body is not a common emergency condition in small hospitals. Accidental ingestion is more frequent in children. Intentional ingestion is usually found in cases of mental disorders, prisoners, attempted suicides, and in persons with intellectual disabilities. The most frequently ingested foreign bodies are pieces of food, most often bones, toothpicks, but real foreign bodies are orthodontic implants, needles, nails etc. [1].

Glass foreign bodies are among the most unusual ingested foreign bodies, and it is difficult to predict the consequences of their passing through the gastrointestinal tract (GIT). We report a case of accidental swallowing of a large quantity of glass pieces, diagnosed by X-ray in the ascending colon and the rectum. The patient did not have signs of perforation, so an expectant attitude was taken, and elimination occurred naturally.

Case report

A 36-year-old woman with intellectual disabilities was admitted to the Clinic due to abdominal pain. Heteroanamnesis showed that she had allegedly had stomach pains for a month. Physical findings showed painful sensitivity in the upper right quadrant, with no signs of peritonitis. The abdominal X-ray showed a great number of intensive shadows in the area of the ascending colon and the rectum (Figure 1). Digital rectal examination produced a lump of stool with pieces of glass.

Upon admission, a computed tomography (CT) of the abdomen was performed (Figure 2). In the area of the ascending colon and the rectum there were numerous hyperdense areas of various shapes and sizes, mostly with sharp contours, and the character of a foreign body, with a density of 500 to 1500 HJ, 5 to 20 mm in diameter. The colonic loop was distended, especially in the area of the transverse colon, with a lumen up to 5 cm in width.

Due to the persistent pain, surgical exploration was considered, but in the absence of signs of perforation, an expectant attitude was taken, and laxatives were prescribed. The patient presented with a gradual regression of pain, and a control X-ray confirmed that the foreign bodies shifted through the intestines (Figure 3 and 4) but they were filled with air, at multiple air fluid levels.

A rectoscopy was performed to establish the condition of the mucous membranes of the rectum, showing intact mucous membranes, with several balls of stool. In each ball there was a piece of glass (Figure 5 a and b).

On the fifth day of hospitalization, X-ray of the native abdomen indicated the absence of glass (Figure 6), but showed several air fluid levels.

On the twelfth day of stay, the patient was discharged in a satisfactory general condition.

Discussion

Most intentionally or accidentally ingested foreign bodies pass through the GIT without complications, and only a minority require surgical intervention [2-4]. The occurrence of abdominal pain alerts the physician of possible complications, primarily perforation with the resulting peritonitis. Fatal cases after ingestion have also been described, due to intestinal obstruction [5].

The intestines have a significant ability to protect themselves from perforation in cases of ingestion of sharp objects, such as glass. When a sharp object is stuck in the intestinal mucous, an area of ischemia with a large central concavity develops. The walls of the intestines increase the lumen at the place of contact, enabling easier passage of the sharp object [6]. Moreover, when a sharp object is swallowed, the flow of the intestinal content and the relaxation of the intestinal walls tend to direct the head of the object to the front, and the sharp end to the back [7]. When it arrives in the colon, the foreign body is covered with faecal material, protecting the intestinal wall.

Isolated groups of glass in the rectum (Figures 1 and 2) cause concern, because it is forgotten that this collection has already passed through the digestive tract, wrapped in stool, which protects the intestinal wall. In this case, the inability of the patient with intellectual disabilities to describe in detail how the ingestion occurred, that is, how the glass entered the GIT, led to difficulties in diagnosis and therapy.

The aim of clinical evaluation was to identify the type, quantity, size and location of the foreign bodies in the rectum. As a rule, removal of a foreign body from the rectum requires experience, with particular care when using various means of extraction, to minimize damage to the mucous membrane. Most foreign bodies can be successfully removed trans-anally, under appropriate anesthesia and using appropriate instruments. Alternative methods are the use of a Foley catheter [8], trans-anal vacuum extraction of glass foreign bodies [9], and trans-anal minimally invasive surgery [10].

Only a small number of foreign body cases, if they go deeper into the sigmoid colon, require extraction by colonoscopy [11]. Rare cases with signs of perforation, peritonitis, or pelvic sepsis, Fouriner gangrene [12], or unsuccessful manual extraction, require open surgery or laparoscopy, by massaging (milking) towards the anus or a colostomy. After removal of the rectal foreign body, a proctosigmoidoscopy is mandatory, to exclude injury to the mucous membrane [13].

Conclusion

In the case presented, it was clearly a matter of glass that had passed through the gastrointestinal tract. The attitude of waiting and monitoring the clinical condition of the patient seemed most appropriate; otherwise unnecessary resection of the large intestine would have been performed. This approach requires a great deal of patience, constant monitoring, and a prompt reaction in the case of intestinal perforation.
Abbreviations

CT    --computed tomography
GIT   --gastrointestinal tract


https://doi.org/10.2298/MPNS1706170D

References

[1.] Ricci S, Massoni F, Schiffino L, Pelosi M, Salesi M. Foreign bodies ingestion: what responsibility? J Forensic Leg Med. 2014;23:5-8.

[2.] Schwartz GF, Polsky HS. Ingested foreign bodies of the gastrointestinal tract. Am Surg. 1976;42(4):236-8.

[3.] Mcpherson RC, Karlan M, Williams RD. Foreign body perforation of the intestinal tract. Am J Surg. 1957;94(4):564-6.

[4.] Maleki M, Evans WE. Foreign-body perforation of the intestinal tract. Report of 12 cases and review of the literature. Arch Surg. 1970;101(4):475-7.

[5.] Betz P, van Meyer L, Eisenmenger W. Fatalities due to intestinal obstruction following the ingestion of foreign bodies. Forensic Sci Int. 1994;69(2):105-10.

[6.] Exner A. Wie schuetzt sich der verdanungstract ver verletzungen durch spitze fremdkoerper. Arch F D Ges Physiol. 1902; 89:253.

[7.] Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, et al. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg. 2006;30(3):372-7.

[8.] Cologne KG, Ault GT. Rectal foreign bodies: what is the current standard? Clin Colon Rectal Surg. 2012;25(4):214-8.

[9.] Johnson SO, Hartranft TH. Nonsurgical removal of a rectal foreign body using a vacuum extractor. Report of a case. Dis Colon Rectum. 1996;39(8):935-7.

[10.] Cawich SO, Mohammed F, Spence R, Albert M, Naraynsingh V. Colonic foreign body retrieval using a modified TAMIS technique with standard instruments and trocars. Case Rep Emerg Med. 2015;2015:815616.

[11.] Lin XD, Wu GY, Li SH, Wen ZQ, Zhang F, Yu SP. Removal of a large foreign body in the rectosigmoid colon by colonoscopy using gastrolith forceps. World J Clin Cases. 2016;4(5):135-7.

[12.] Abate G, Shirin M, Kandanati V Fournier gangrene from a thirty-two-centimeter rectosigmoid foreign body. J Emerg Med. 2013;44(2):e247-9

[13.] Ayantunde AA. Approach to the diagnosis and management of retained rectal foreign bodies: clinical update. Tech Coloproctol. 2013;17(1):13-20.

Rad je primljen 23. II 2017.

Recenziran 28. III 2017.

Prihvacen za stampu 18. IV 2017.

BIBLID.0025-8105:(2017):LXX:5-6:170-172.

Samir DELIBEGOVIC (1), Edvin MULALIC (1) and Sejo BUTUROVIC (2)

University Clinical Center Tuzla, Surgery Clinic, Department of Colorectal Surgery, Tuzla, Bosnia and Herzegovina (1)

General Hospital, Konjic, Bosnia and Herzegovina (2)

Corresponding Author: Prof, dr Samir Delibegovic, Univerzitetski klinicki centar, Klinika za hirurgiju, 75000 Tuzla, Trnovac bb, E-mail: delibegovic.samir@gmail.com

Caption: Figure 1. Abdominal X-ray showing a great number of intensive shadows in the area of the ascending colon and the rectum Slika 1. Rendgenogram abdomena pokazuje veci broj intenzivnih senki u podrucju ascedentnog kolona i rektuma

Caption: Figure 2. Abdominal CT in the area of the ascending colon and the rectum showing numerous hyperdense areas Slika 2. Kompjuterizovana tomografija abdomena, u podrucju ascedentnog kolona i rektuma veci broj hiperdenznih area

Caption: Figures 3 and 4. The X-ray confirmed that the foreign bodies shifted through the intestines, but they were filled with air at several air fluid levels Slike 3 i 4. Rendgenogram abdomena pokazuje pomeranje stranih tela kroz creva, ali crevima ispunjenim vazduhom i sa nekoliko aerolikvidnih nivoa

Caption: Figure 5 a and b. One of the balls of stool containing a piece of glass Slika 5 a i b. Jedna od "kuglica" stolice u kojoj se nalazi komadic stakla

Caption: Figure 6. X-ray of the native abdomen indicated the absence of glass Slika 6. Rendgenogram nativnog abdomena ukazuje na odsustvo stakla, ali sa nekoliko aerolikvidnih nivoa
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Title Annotation:Case report/Prikaz slucaja
Author:Delibegovic, Samir; Mulalic, Edvin; Buturovic, Sejo
Publication:Medicinski Pregled
Article Type:Case study
Geographic Code:4EXBO
Date:May 1, 2017
Words:1493
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