Duodenal Perforation due to Ingested Partial Denture

Ingestion of foreign bodies including dentures can be a cause of morbidity and mortality. We report a case of poor-fit denture in an elderly male with pulmonary and musculoskeletal comorbidities, who presented as an acute abdomen. The pin attached to the denture caused perforation of first part of duodenum. The only positive finding prior to surgery was a radiopaque density in the abdominal radiograph of the patient and air under the diaphragm. It is important for all the surgeons dealing with acute care patients to be aware of different designs and constructions of dentures.

Gastrointestinal perforation secondary to accidental ingestion of toothpicks: A series case report

RATIONALE

Toothpicks are widely used as a tooth cleaning tool after meals in China. Most of the Chinese toothpicks are made of wood or bamboo with a hard texture and sharp ends. This characteristic has proven to be potentially dangerous when toothpicks are accidentally ingested, as they can cause damage and perforation of the digestive tract and other subsequent complications.

PATIENT CONCERNS

The main clinical complaints of 5 patients in this study were mainly acute or chronic abdominal pain, duration from 2 days to 2 months, 1 case with vomiting, 1 case with fever.

DIAGNOSES

Four cases were initially diagnosed by computed tomography (CT) scan; However, the first case was misdiagnosed as appendicitis so the patient did not undertake a preoperative CT scan and it was diagnosed by laparoscopy.

INTERVENTIONS

All the cases were treated by laparoscopy and the toothpicks were removed successfully.

OUTCOMES

Toothpick-caused digestive perforation was confirmed by laparoscopy in all this 5 cases, the perforation sites were 2 cases at the antrum of stomach, 1 case at the third part of duodenum, 1 case at the ileocecal junction and 1 case at the sigmoid colon. 4 cases had perforation repair . Operative time :48-67 min. Intraoperative bleeding: 25-80 ml. 1 patient had a secondary liver injury. No postoperative complications occurred in all cases. The length of hospital stay was between 4-25 days.

LESSONS

Our case series study suggests that laparoscopy is a safe and feasible surgical procedure for definitive management of digestive tract perforation by toothpick ingestion. We also suggest all the people should have healthy life behaviors and use the toothpicks correctly.

Nontraumatic large bowel perforation: spectrum of etiologies and CT findings

Large bowel perforation is an abdominal emergency that results from a wide range of etiologies. Computed tomography is the most reliable modality in detecting the site of large bowel perforation. The diagnosis is made by identifying direct CT findings such as extraluminal gas or contrast and discontinuity along the bowel wall. Indirect CT findings can help support the diagnosis, and include bowel wall thickening, pericolic fat stranding, abnormal bowel wall enhancement, abscess, and a feculent collection adjacent to the bowel. Common etiologies that cause large bowel perforation are colon cancer, foreign body aspiration, stercoral colitis, diverticulitis, ischemia, inflammatory and infectious colitides, and various iatrogenic causes. Recognizing a large bowel perforation on CT can be difficult at times, and there are various entities that may be misinterpreted as a colonic perforation. The purpose of this article is to outline the MDCT technique used for evaluation of suspected colorectal perforation, discuss relevant imaging findings, review common etiologies, and point out potential pitfalls in making the diagnosis of large bowel perforation.

Differentiating perforated from non-perforated appendicitis on contrast-enhanced magnetic resonance imaging

BACKGROUND

The role of magnetic resonance imaging (MRI) in pediatric appendicitis is increasing; MRI findings predictive of appendiceal perforation have not been specifically evaluated.

OBJECTIVE

To assess the performance of MRI in differentiating perforated from non-perforated appendicitis.

MATERIALS AND METHODS

A retrospective review of pediatric patients undergoing contrast-enhanced MRI and subsequent appendectomy was performed, with surgicopathological confirmation of perforation. Appendiceal diameter and the following 10 MRI findings were assessed: appendiceal restricted diffusion, wall defect, appendicolith, periappendiceal free fluid, remote free fluid, restricted diffusion within free fluid, abscess, peritoneal enhancement, ileocecal wall thickening and ileus. Two-sample t-test and chi-square tests were used to analyze continuous and discrete data, respectively. Sensitivity and specificity for individual MRI findings were calculated and optimal thresholds for measures of accuracy were selected.

RESULTS

Seventy-seven patients (mean age: 12.2 years) with appendicitis were included, of whom 22 had perforation. The perforated group had a larger mean appendiceal diameter and mean number of MRI findings than the non-perforated group (12.3 mm vs. 8.6 mm; 5.0 vs. 2.0, respectively). Abscess, wall defect and restricted diffusion within free fluid had the greatest specificity for perforation (1.00, 1.00 and 0.96, respectively) but low sensitivity (0.36, 0.25 and 0.32, respectively). The receiver operator characteristic curve for total number of MRI findings had an area under the curve of 0.92, with an optimal threshold of 3.5. A threshold of any 4 findings had the best ability to accurately discriminate between perforated and non-perforated cases, with a sensitivity of 82% and specificity of 85%.

CONCLUSION

Contrast-enhanced MRI can differentiate perforated from non-perforated appendicitis. The presence of multiple findings increases diagnostic accuracy, with a threshold of any four findings optimally discriminating between perforated and non-perforated cases. These results may help guide management decisions as MRI assumes a greater role in the work-up of pediatric appendicitis.

Differentiation of cancerous and inflammatory colorectal perforations using multi-detector computed tomography

PURPOSE

To determine reliable CT features to distinguish cancerous from inflammatory colorectal perforations.

MATERIALS AND METHODS

A total of 43 patients with surgically and pathologically confirmed colorectal perforation caused by either colorectal cancer (n =27) or an inflammatory conditions (n = 16) were identified. Two radiologists independently assessed the contrast-enhanced CT features for locations of perforation, mural configurations, soft-tissue alterations, lymphadenopathy, and metastases. Intergroup comparisons for univariate analysis were performed using Fisher's exact test or chi-square test for categorical data and Mann-Whitney test for numeric data. Stepwise logistic regression analysis was conducted with features that were found significant under the univariate analysis. Interobserver agreement was assessed using intraclass correlation coefficient (ICC) and kappa test.

RESULTS

Maximal mural thickness >1.39 cm (sensitivity, 100%; specificity, 68.75%), luminal mass or shoulder formation (sensitivity, 88.89%; specificity, 68.75%), absence of diverticula (sensitivity, 96.30%; specificity, 50.00%), irregular mural thickening (sensitivity, 92.59%; specificity, 81.25%), lymphadenopathy (sensitivity, 40.74%; specificity, 93.75%), and metastases (sensitivity, 25.93%; specificity, 100%) were significantly frequent in cancerous perforations. The maximal mural thickness (P = 0.0493, odds ratio = 439.83) and irregular mural thickening (P = 0.0343, odds ratio = 4.69) were identified as the highly distinguished identifiers.

CONCLUSIONS

The CT manifestations of cancerous and inflammatory colorectal perforations overlap. Definitive diagnosis is not always possible with imaging alone. The maximal mural thickness >1.39 cm and irregular configuration of the thickened bowel wall were the two highly statistically significant CT features that may help order the difference between the two entities.

A Case of Incarcerated and Perforated Stomach in Delayed Traumatic Diaphragmatic Hernia

The patient was an emergency transported, 57-year-old man complaining of left thoraco-lateroabdominal pain, with a history of blunt chest trauma 3 months prior. Thoracoabdominal computed tomography (CT) resulted in a diagnosis of diaphragmatic hernia with incarceration and perforation of the stomach, and same-day emergency surgery was performed. The surgery was performed via an abdominal approach, and after manually repositioning the stomach incarceration, the perforated region was resected and the diaphragm sutured closed. Diaphragmatic hernia can be occasionally difficult to diagnose at the time of initial treatment, and may have been overlooked at the initial presentation, 3 months earlier in the present case. When examining a case of blunt force thoracoabdominal trauma, it is important to keep in mind the possibility of diaphragmatic injury. Additionally, during surgery for traumatic diaphragmatic hernia, in cases where manipulation of the abdominal organs is thought necessary, commencing the surgery with an abdominal approach is desirable.

Rectal perforation secondary to transanal haemorrhoidal dearterialisation

Haemorrhoidal artery ligation has now been established as a treatment modality for symptomatic haemorrhoids. We report a case of a fit 44-year-old male who underwent the procedure as a day case, who subsequently developed pelvic sepsis due to rectal perforation. This case is the first report of a potentially life-threatening complication resulting from this procedure, which has a previously excellent safety profile.

[Chilaiditi syndrome - a case report]

The abnormality being the result of a certain transposition of the large intestine winding in between diaphragm and the liver, owes it's name to a so called Chilaiditi symptom. This symptom is rarely recognized for at most 0,025-0,28% of the whole population statistics - wise. The Chilaiditi symptom can be examined without any serious (abdominal) pain indication, when conducting the gastrointestinal examination with the implication of the different disorders. When carrying out the diagnostic examination, it is strongly recommended to take notice of patients suffering from the pain in abdominal area, especially in case of the patients with the developed air - structure under the right side copula of the diaphragm. The transposition of the large instestine winding between the diaphragm and the liver, may lead to the blood structure disorders along the part of patient's spot - pressed intestine and be the cause of the other afflictions. The circumstance as such is thus called by the name of Chilaiditi syndrome. The respective recognition of this syndrome may prevent the patient from any unnecessary assignment for a diagnostic and (or) any other therapeutic procedures in place.It may as well minimize the overall diagnostic treatment time lapse - usually concentrated on the pain relief treatment in the aftermath. The patients without examined affliction, (ex.) due to the liver disorders and the awareness of the existence of this syndrome in general, can be an indicator for taking up a decision for when it comes to the liver biopsy. This due to the risk of any perforation of the digestive tract.

A CASE REPORT

The report describes case of the 56-year-old male patient, directed onto the surgery department by cause of a quite significant epigastric pain in the right side of the abdomen, however without any of the peritoneal symptoms indicated. The x-ray examination of the chest has indicated presence of the air - structure under the diaphragm copula. Having stated that and without any other signals of the serious abdominal inflammation, this symptom gave trigger for the assumption of the gastrointestinal perforation. As a result, the tomography scan has revealed high curve placement of the diaphragm going along the patient's front lobe of the liver. In the result the Chilaiditi syndrome has been recognized by the patient, where the symptom based treatment has prescribed leading the same to the absolute healing results as an outcome. After leaving the surgery by the patient, it has been made use of the re-directory to the leading gastroenterology practice for any further control checks. In the aftermath of the several year long observation, none of the abdominal pains have been reported back.

CONCLUSIONS

Presence of the air - structure under the diaphragm copula without any typical affliction in relation to digestive tract perforation might be the result of transposition of the large intestine winding between diaphragm and the liver - called the Chilaiditi syndrome.

Abdominal manifestations of fishbone perforation: a pictorial essay

PURPOSE

The present article provides an overview of the spectrum of abdominal presentations of fishbone (FB) ingestion and its complications.

METHODS

In image data from 9 patients, FB perforations were found in different levels of the gastrointestinal tract (GIT), including duodenal, jejunal, and sigmoid perforations; in 4 asymptomatic patients, FBs were observed in the mesentery, falciform ligament, and intestinal bowel.

RESULTS

The main imaging features of FB perforation were focal gastric or intestinal wall thickening, fat stranding, bowel obstruction, ascites, localized pneumoperitoneum, intra-abdominal abscess, liver abscess, and a linear hyperdense structure in the abdominal cavity in the GIT or within a parenchymal organ often surrounded by inflammatory changes. Free pneumoperitoneum was rare.

CONCLUSION

Although in most cases, a FB does not cause any serious complications, an inflammatory process and complications may occur when it perforates the stomach or bowel loops. Radiologists need to be aware of the possibility of FB perforation, especially in high-risk patients, because it is not always considered in the differential diagnosis by referring physicians and can mimic other inflammatory conditions and tumoral lesions.

Stercoral perforation of the rectum with faecal peritonitis and pneumatosis coli: A case Report

Colonic perforation due to impacted faeces or faecaloma is a relatively uncommon presentation with grave prognosis. If left untreated, it can be life threatening due to complications like faecal peritonitis. Till date, fewer than 150 cases have been reported mostly in the English surgical literature describing constipation as the most common underlying etiology. Involvement of rectum is rare with very limited data published in this context. We present a case of stercoral perforation involving the rectum with associated faecal peritonitis and pneumatosis coli.

Large retroperitoneal abscess extended to the inferior right limb secondary to a perforated ileal Crohn's disease: the importance of the multidisciplinary approach

The typical complications of Crohn's disease concerns small and large bowel. The full thickness inflammation of the intestinal wall develops in strictures, fistulas and abdominal abscesses. Nowadays the most accepted therapeutic for intra-abdominal abscess option is antibiotic therapy and, in case of need, percutaneous drainage of the abscess. If the abscess passes through the pelvic foramen the abscess can involve the inferior limbs. We report a case a perforation of terminal ileum in Crohn's disease complicated by a large abscess of the right iliac fossa reaching the spaces between the anterior lateral muscles of the right thigh as far as the anterior lateral pre-tibial region. We discuss the diagnostic and therapeutic options in a multidisciplinary context.

Multiple perforation of small-intestine diverticula in a patient with Ehlers-Danlos syndrome

Ehlers-Danlos syndrome represents a group of hereditary connective tissue disorders characterized by ligamentous hyperlaxity, fragile skin and joint hypermobility. Gastrointestinal complications in this syndrome are less well known.

Rectal perforation during defecography: extraluminal barium impaction removed by TEM (Transanal Endoscopic Microsurgery)

AIM

Defecography is the standard diagnostic technique for the diagnosis of functional disorders of the posterior pelvic compartment. However it has some limits as radiation exposure, low-contrast resolution, some degrees of embarrassment and discomfort for the patients. Furthermore it often fails to directly visualize the changes that affect the pararectal space. Here we present a never described case of rectal perforation after defecography with barium impaction removed by TEM (Transanal Endoscopic Microsurgery).

CASE REPORT

We present a case of a 50 years old woman with extraluminal barium impaction due to perforation occurred during defecography. Both pelvic MR and endoanal ultrasound confirmed the presence of the extramural rectal mass below rectal mucosa. It was completely and safely removed using transanal endoscopic microsurgery (TEM).

RESULTS

The barium impaction has been radically removed using transanal endoscopic microsurgery. The post-operative period was uneventful and the patient was discharged 3 days after the operation. She is asymptomatic after 6 months from surgery.

CONCLUSION

Defecography is not completely safe and its use must be indicated only in selected cases. When a patient has complications during or after this investigation he must be referred to a specialistic centre where a tailored treatment can be performed. It is mandatory that the indication for defecography and other diagnostic functional investigations is given by a colorectal specialist KEY WORD: Barium Impaction, Defecography, Rectal Perforation, TEM (Transanal Endoscopic Microsurgery).

[A Case of Small Intestinal Malignant Lymphoma Presenting with Perforated Peritonitis]

An 85-year-old man presented to the emergency department with vomiting. He had tenderness in the left abdomen and under the umbilicus. Laboratory data showed an increase in the inflammatory response. Enhanced abdominal computed tomography showed thickening ofthe small intestinal wall in the lower left abdomen with a small amount ofadjacent free air. The fat tissue around the small intestine also revealed a high density area suggestive of inflammation. A diagnosis of peritonitis caused by intestinal perforation was made and an emergency operation was performed. We resected part of the ileum about 90 cm from the ileum end. The resected specimen showed a 1 by 1 cm mass with an ulcer and perforation at the base of the tumor. Histopathological findings revealed densely increased numbers of monomorphic medium-sized lymphoma cells infiltrating into all layers ofthe intestine. Immunohistochemically, the lymphocytes were positive for CD3, CD20, CD30, and CD79a. We diagnosed diffuse large B-cell lymphoma. Two cycles ofchemotherapy were given post-operatively. A recurrence was not observed. After chemotherapy he was transferred to rehabilitation.

Management of gastrointestinal perforation from blunt and penetrating abdominal trauma in children: analysis of 96 patients

AIM

The objective of the present study was to evaluate the diagnostic methods, concomitant organ injuries, factors affecting mortality and morbidity, treatment methods, and outcomes of patients treated for traumatic gastrointestinal (GI) perforation.

MATERIALS AND METHODS

We conducted a retrospective review of the medical records of 96 patients who had been treated for GI perforation between January 2000 and October 2015. Data were collected and organised according to the following categories: general patient information, age, gender, hospitalisation period, trauma mechanisms, concomitant injuries, radiological assessment, diagnosis and treatment methods, treatment forms, and complications. The cases were divided into two groups, blunt and penetrating traumas, and the patients within each group were compared. Colorectal trauma cases were not included in this study. Patients suspected of a GI perforation were assessed by standing plain abdominal radiograph (SPAR) and ultrasound scan (US). Patients who had a normal SPAR, and showed free or viscous fluid in the abdomen on US underwent computed tomography (CT) scanning. Surgery was performed if patients displayed free air in the abdomen on a SPAR or CT scan, showed viscous fluid without any additional injury, provided normal radiological images but displayed signs of peritonitis, or were clinically unstable. The patients were scored according to the Injury Severity Score (ISS) system.

RESULTS

In total, 96 patients, with an average age of 10.3 ± 4 years (1-17 years) and diagnosed with a GI perforation, were reviewed retrospectively. The patients included 88 (91 %) males and 8 (9 %) females. The presence of free air on SPAR was detected in 42 (52 %) patients, whereas no free air was detected in 39 (48 %) patients. Non-specific significant findings were detected in 45 (76 %) out of 59 patients by USS, and in 78 % of patients by CT (viscous fluid, fluid, free air). The most affected organ was the ileum, which was detected in 37 (39 %) patients. Primary repair was performed on 71 (74 %) patients, while resection was performed on 22 (23 %); 3 (3 %) patients underwent an ostomy. Ten (10 %) patients experienced complications and five (5 %) patients died. The ISS scores for blunt and penetrating traumas were 14, 15 and no significant difference was detected between the scores (p > 0.05).

CONCLUSIONS

Although the complication rate for patients with penetrating trauma was higher than for those with blunt trauma, the rate of mortality increased in patients with blunt trauma. Free air may not be detected by SPAR even if a GI perforation exists. Since diagnostic challenges may increase the rate of mortality and morbidity in GI perforations, we believe that a combination of radiological imaging and rapid abdominal examination is important in cases where SPAR cannot detect free air.

Core curriculum illustration: blunt trauma to the bowel

This is the 22nd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .