Introduction

Foreign body ingestion is a common occurrence across healthcare services, with pediatric patients being disproportionately affected¹. In most cases (80%-90%), foreign bodies that pass through the gastrointestinal tract do not cause any harm; however, some patients experience complications such as bleeding, ulceration, mucosal erosion, local scarring, or perforation².

The clinical presentation of intestinal perforations is typically acute and rapidly progressive, necessitating urgent surgical intervention. The foreign bodies most frequently associated with this complication include fish bones, chicken bones, toothpicks, and dentures, among others^2,3. In terms of management, patients without clinical deterioration are often placed on watchful waiting. However, in approximately 10%-20% of cases where complications arise, endoscopic intervention is required, while 1% of patients require urgent surgical procedures¹.

This case report describes an elderly female patient who presented to the emergency department with acute abdominal pain and underwent surgery, during which an incidental foreign body was identified as the cause of intestinal perforation. The objective of this report is to highlight how foreign body ingestion can lead to significant clinical deterioration in some patients.

Case description

The patient was a 72-year-old female with a medical history of arterial hypertension and breast cancer, presenting with a four-day history of generalized abdominal pain accompanied by distension and nausea. An external abdominal ultrasound had revealed a renal cyst and cholelithiasis. Due to persistent symptoms, she was admitted to the emergency department. Upon initial assessment, she presented with generalized abdominal pain, predominantly in the mesogastrium, and significant abdominal distension.

Laboratory tests revealed hypocalcemia, elevated nitrogenous waste levels, hypoglycemia, moderate hypokalemia, and arterial blood gases indicative of metabolic acidosis. Radiographic and contrast-enhanced abdominal and pelvic CT scans showed signs of hollow intestinal loop rupture, free fluid, and inflammatory changes in the peritoneum. Additionally, the imaging revealed a linear hyperdense structure in the left adnexal region and sigmoid colon, along with a right cortical renal cyst and cholelithiasis (Figure 1).

Figure 1
Abdominal and pelvic CT scan showing signs of hollow intestinal loop rupture, free fluid, inflammatory changes in the peritoneum, and a linear hyperdense structure in the left adnexal region and sigmoid colon. Image courtesy of the Radiology Department, Fundación Cardiovascular de Colombia. Bucaramanga, Colombia.

The patient was evaluated by the surgical team, who decided to perform an urgent exploratory laparotomy. Intraoperatively, diffuse peritonitis involving all four abdominal quadrants was observed (with 1600 mL of purulent fluid), as well as evidence of rectal perforation caused by a foreign body (a chicken bone) (Figure 2). A partial colectomy and colostomy were performed, and the foreign body was removed (Figure 3). Postoperatively, the patient required intensive care unit (ICU) monitoring and was administered a broad-spectrum antibiotic regimen for one week.

Figure 2
Intraoperative finding of mid-rectal perforation caused by a foreign body (chicken bone). Image courtesy of the Surgery Department, Fundación Cardiovascular de Colombia. Bucaramanga, Colombia.

Figure 3
A. Partial colectomy specimen and extracted foreign body. B. Extracted chicken bone, measuring 5 cm in length. Source: Surgery Department, Fundación Cardiovascular de Colombia. Bucaramanga, Colombia.

Discussion

Foreign body ingestion is generally not a clinical concern, but in some cases, it can lead to significant complications. A direct relationship has been reported between the size of the foreign body and the location of the complication. Specifically, objects thicker than 2 cm and longer than 6 cm rarely pass through the gastrointestinal tract⁴. It is important to note that not all foreign bodies are visible using certain radiological studies; for instance, wooden splinters and some plant thorns are not detectable on standard X-rays.

Certain conditions, such as stenotic lesions, fistulas, or diverticula, increase the risk of complications associated with foreign body ingestion. In cases involving chicken bone ingestion-considered a sharp object-the rate of gastrointestinal tract complications has been estimated to be as high as 35%¹.

Preoperative diagnosis of perforations is rare, as their clinical presentation can be non-specific, especially in cases of peritonitis, abscesses, enterovesical fistulas, obstructions, or hemorrhages, all of which can mimic other surgical pathologies. Common symptoms in such cases, as well as in other reported patients, include abdominal pain and distension lasting several days⁵. The most frequent sites of perforation are the distal ileum, cecum, and left colon. Contrast-enhanced computed tomography (CT) is one of the recommended diagnostic methods for such cases, as reported in the literature, as it can detect small objects such as bones^6-8. Additionally, for cases in which bones have not passed the proximal duodenum, endoscopy is advised⁹.

Surgical treatment should be individualized. In patients without hemodynamic involvement, conservative management may be effective; however, in patients presenting with acute abdomen due to intestinal perforation, surgical resection is the optimal approach¹⁰.

Conclusions

Foreign bodies that enter the gastrointestinal system generally do not cause any clinical implications for patients. However, larger objects can cause complications in various parts of the digestive system. One such complication is intestinal perforation, which can occur due to the narrowing and angulation of the gastrointestinal tract. In these cases, surgical intervention involving colonic resection is necessary.

Referencias

Dines JT, Harvey A. Chronic intentional chicken bone ingestion mimicking inflammatory bowel disease. BMJ Case Rep. 2021;14(6):e239022. https://doi.org/10.1136/bcr-2020-239022

Hoxha FT, Hashani SI, Komoni DS, Gashi-Luci LH, Kurshumliu FI, Hashimi MSh, et al. Acute abdomen caused by ingested chicken wishbone: a case report. Cases J. 2009;2(1):64. https://doi.org/10.1186/1757-1626-2-64

Simunic M, Zaja I, Ardalic Z, Stipic R, Maras-Simunic M. Case report: successful endoscopic treatment of a large bowel perforation caused by chicken bone ingestion. Medicine (Baltimore). 2019;98(50):e18111. https://doi.org/10.1097/MD.0000000000018111

Sánchez Vallejo G, Osorio Correa EI, Barrera López AM, Cardona CA. Cuerpos extraños en tracto gastrointestinal asociados a trastorno mental: reporte de caso. Rev Colomb Gastroenterol. 2009;24(1):79-85.

Boland PA, Quidwai ST, Mitru R, McCarthy E, Aremu M. Sigmoid Perforation Secondary to Accidental Ingestion of a Chicken Bone. Ir Med J. 2020;113(1):12.

Venkatesh SH, Venkatanarasimha Karaddi NK. CT findings of accidental fish bone ingestion and its complications. Diagn Interv Radiol. 2016;22(2):156-60. https://doi.org/10.5152/dir.2015.15187

Dávila Arias C, Guirado Isla L, González Ortega J. Meckel’s diverticulum perforated by a foreign body: a rare cause of abdominal pain. Rev Esp Enferm Dig. 2019;111(11):891-892. https://doi.org/10.17235/reed.2019.6547/2019

Manco G, Caramaschi S, Malagoli M, Bonetti LR, Rossi A. Laparoscopic treatment of Meckel’s diverticulum perforation caused by a chicken bone. A case report. Ann Ital Chir. 2020;9:S2239253X20032740.

ASGE Standards of Practice Committee; Ikenberry SO, Jue TL, Anderson MA, Appalaneni V, Banerjee S, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-91. https://doi.org/10.1016/j.gie.2010.11.010

Rasheed AA, Deshpande V, Slanetz PJ. Colonic perforation by ingested chicken bone. AJR Am J Roentgenol. 2001;176(1):152. https://doi.org/10.2214/ajr.176.1.1760152

Notes

Author notes

*Correspondence: Gianmarco Camelo-Pardo. gcamelo3@estudiantes.areandina.edu.co

Conflict of interest declaration