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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 54-56

Distal ileal perforation due to accidental ingestion of meat bone mimicking acute appendicitis


1 Department of General and Laparoscopic Surgery, Prince Mohammed Bin Nasser Hospital, Jazan, Kingdom of Saudi Arabia
2 Department of General and Laparoscopic Surgery, Sabya General Hospital, Jazan, Kingdom of Saudi Arabia

Date of Submission19-Jul-2018
Date of Acceptance24-Jul-2018
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Abdu Hasan Ayoub
Department of General and Laparoscopic Surgery, Prince Mohammed Bin Nasser Hospital, Jazan
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJL.SJL_9_18

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  Abstract 

Foreign body (FB) ingestion is quite frequently seen in clinical practice while intestinal perforation due to it is infrequent. Preoperative diagnosis is quite challenging once the history is inconsistent. We report herein, a young male patient who presented to the emergency department with acute abdomen a day after taking sheep meat with unnoticed ingestion of bone, where a clinical diagnosis of acute appendicitis was made, later came out distal ileal perforation due to “meat bone” that was protruded into the abdominal cavity. The bone was removed and perforation closed through endo stitch. The report of this case highlights the risk of missing the unusual causes of acute abdomen if the history is incomplete or the FB is radiolucent. Surgeons treating acute abdomen should keep the uncommon causes in mind once the common causes are excluded from the study.

Keywords: Appendicitis, foreign body, ileum, meat bone, perforation


How to cite this article:
Ayoub AH, Fagihi MA, Abdul-Aal HS, Abiri AA, Al-Nam AQ, Khan LA. Distal ileal perforation due to accidental ingestion of meat bone mimicking acute appendicitis. Saudi J Laparosc 2019;4:54-6

How to cite this URL:
Ayoub AH, Fagihi MA, Abdul-Aal HS, Abiri AA, Al-Nam AQ, Khan LA. Distal ileal perforation due to accidental ingestion of meat bone mimicking acute appendicitis. Saudi J Laparosc [serial online] 2019 [cited 2019 Dec 5];4:54-6. Available from: http://www.saudijl.org/text.asp?2019/4/1/54/267864


  Introduction Top


Foreign body (FB), such as a fish or chicken bone ingestion whether intentionally or accidentally, is quite frequently seen in clinical practice. Most of the FB passes the intestinal tract without any complication, while 1% of cases make complications including bowel perforation.[1] The patient's clinical symptoms vary from abdominal pain with or without a fever to focal or diffuse peritonitis that requires surgical intervention. Preoperative diagnosis is seldom made once the history is inconsistent.

We report the first case of “sheep meat bone-induced distal ileal perforation” in a 23-year-old Indian patient presented to our emergency room (ER) at Prince Mohammed Bin Nasser Hospital, Jazan, Kingdom of Saudi Arabia.


  Case Report Top


A 23-year-old Indian farmer referred from a private polyclinic to our hospital's ER with a history of abdominal pain, first started in the peri-umbilical area, then become generalized for the last 2 days associated with nausea. The patient gives neither history of any medical, surgical, nor psychiatric illnesses. The clinical evaluation revealed no other findings except rigid, tender abdomen with positive rebound tenderness.

Vital signs included temperature 37 C, pulse 98/min, blood pressure 103/57 mmHg, and oxygen saturation of 100% at room air. Laboratory workup on admission showed white blood cell 15.2, hemoglobin 6.9 g/dl, hematocrit 22.3, Na+ 136.9 mmol/L, K+ 4.3 mmol/L, Creat 91 mol/L, TBill 21 mol/L, prothrombin time 13.8 s, activated partial thromboplastin time 42.6 s, and international normalized ratio 1.14. Chest X-ray showed no air under the diaphragm.

The clinical diagnosis of acute appendicitis was made, and a laparoscopic appendectomy was planned for the patient. Intraoperative findings were normal looking appendix and visible FB bone coming out through lumen of the small intestine [Figure 1] and [Figure 2], 30–50 cm of the terminal ileum. FB (meat bone) extracted [Figure 3] while perforation [Figure 4] was closed through endo stitch, keeping appendix in situ. After gaining fully consciousness from GA, the condition was explained to the patient and asked him about recent food intake, then, the patient admit that he took sheep meat a day before he started the abdominal pain.
Figure 1: Intraoperative view of the bone protruding from the distal ileum

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Figure 2: Intraoperative view of the bone removal from the distal ileum

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Figure 3: Postoperative view of the bone removed from the distal ileum

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Figure 4: Intraoperative view of the perforation at distal ileum

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During his stay in the male surgical unit, patients had an uneventful recovery and discharged on the 4th postoperative day. On his 1st follow-up visit in the surgical outpatient department after a week, the patient was doing well.


  Discussion Top


Unintentional, unconscious FB ingestions in otherwise healthy controls are usually dietary.

Foreign bodies such as dentures, fish bones, chicken bones, toothpicks, and cocktail sticks have been known to cause bowel perforation.[2]

The anatomical sites where FB impaction is most likely include narrow, angled or pouching zones, zones with adhesions or surgical anastomosis, and zones containing a diverticulosis.[1] Intestinal perforation secondary to ingestion of foreign materials may clinically mimic acute appendicitis or diverticulitis, especially in cases with terminal ileum involvement, which is the most frequent site for perforations. Patients are operated on for acute appendicitis,[3],[4] as seen in our patient.

Preoperative diagnosis mainly depends on proper history taking, physical evaluation along with radiographic findings, while an accurate diagnosis of the cause and level of perforation is essential for therapeutic planning, which is quite challenging.

The patient is usually treated as acute abdomen and open or laparoscopic approach is considered in case the cause is not clear, that provides an important diagnostic and therapeutic method in the evaluation and treatment of FB perforations,[5],[6] as seen in our case, where laparoscopic procedure was performed.


  Conclusion Top


The report of this case highlights the risk of missing the unusual causes of acute abdomen if the history is incomplete or the FB is radiolucent. Surgeons treating acute abdomen should keep the uncommon causes in mind once the common causes are excluded from the study.

Consent

Written informed consent was obtained from the patient for publication of this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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;30:372-7.  Back to cited text no. 1
    
2.
Akhtar S, McElvanna N, Gardiner KR, Irwin ST. Bowel perforation caused by swallowed chicken bones – A case series. Ulster Med J 2007;76:37-8.  Back to cited text no. 2
    
3.
Hsu SD, Chan DC, Liu YC. Small-bowel perforation caused by fish bone. World J Gastroenterol 2005;11:1884-5.  Back to cited text no. 3
    
4.
Perko Z, Bilan K, Pogorelić Z, Druzijanić N, Srsen D, Kraljević D, et al. Acute appendicitis and ileal perforation with a toothpick treated by laparoscopy. Coll Antropol 2008;32:307-9.  Back to cited text no. 4
    
5.
Law WL, Lo CY. Fishbone perforation of the small bowel: Laparoscopic diagnosis and laparoscopically assisted management. Surg Laparosc Endosc Percutan Tech 2003;13:392-3.  Back to cited text no. 5
    
6.
Saad SK, Ismail TM, Khuder HA. Small bowel perforation secondary to fish bone ingestion. Bahrain Med Bull 2010;32:4.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
References
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