Perforated acute abdomen is a common syndrome among nontraumatic abdominal emergencies
[1]. Bowel perforations may occur because of inflammatory, neoplastic, traumatic, or
infectious processes in the digestive tract [2]. They can also be due to ingestion of foreign bodies or as a result of diagnostic
and therapeutic medical procedures [2]. The bowel perforation can present as diffuse peritonitis, when it occurs in free
peritoneum, or as an obstructive process [3].
Bowel perforation is unusual after foreign body ingestion. However, it can occur when
the object is long and pointed, in areas of physiological or pathological narrowing
[4]. We describe a case of bowel perforation in the sigmoid colon that was caused by
a foreign body, namely a toothpick, and treated endoscopically.
A 14-year-old boy presented with abdominal pain in the right iliac fossa and hypogastrium,
nausea, and headache. He was feverish and had experienced an episode of diarrhea.
Laboratory tests showed leukocytosis and elevation of C-reactive protein. Inconclusive
radiological evaluation with abdominal ultrasound showed inflammatory changes of mesenteric
fat in the right iliac fossa and hypogastrium. Abdominal computed tomography showed
a thickening of the wall of the sigmoid colon, about 23 cm from the anal margin, fat
stranding, and an extraluminal air bubble. The cecal appendix was unchanged. Completion
of the examination using rectal contrast showed an image suggestive of a foreign body
causing perforation of the colon ([Fig. 1]).
Fig. 1 A 14-year-old boy presented with pain in the right iliac fossa and hypogastrium,
nausea, headache, and fever, and had experienced an episode of diarrhea. Abdominal
computed tomography (CT) showed a foreign body in the sigmoid, associated with fat
stranding and presence of pneumoperitoneum.
An endoscopic examination was done, with bowel preparation using only 1000 mL of glycerin
enema administered rectally. A toothpick was seen to be piercing the wall of the sigmoid
colon ([Fig. 2]). The available tools did not allow us to grasp the toothpick in such a way that
we could free it from the sigmoid wall. We therefore attached a metal clip (HX 610-135,
disposable endoscopic; Olympus Medical, Japan) to the toothpick; a polypectomy snare
(Captivator, small oval, stiff, 13 mm; Boston Scientific, Costa Rica) was closed around
the clip. We then used traction and countertraction movements, to remove the toothpick
from the colonic wall ([Fig. 3]).
Fig. 2 Colonoscopy showed a toothpick piercing the wall of the sigmoid colon.
Fig. 3 a Clip grasping the removed toothpick. b Traction had been obtained by using the polypectomy snare closed around the clip.
The patient progressed satisfactorily, without complications and was discharged after
48 hours. He was ingesting a bland diet, had normal bowel movements, and was taking
oral antibiotics. He had no complaints at outpatient 15-day follow-up and was discharged
to return to normal daily activities.
Endoscopy_UCTN_Code_TTT_1AQ_2AH
