Denture Ingestion, Gastrointestinal Transit and Subsequent Complications in a 75-Year-Old Male: A Case Report

Abstract

Introduction

Foreign body ingestion is a common clinical occurrence, often resolving spontaneously as the object passes through the gastrointestinal tract. We present a unique case of sigmoid perforation with an associated local abscess, successfully managed with sigmoidectomy and direct anastomosis.

Case Presentation

A 75-year-old male presented to the emergency department after accidentally ingesting his dentures. Conservative management was attempted initially. Four days later, the patient developed abdominal pain. Computed tomography scan revealed signs of perforation, and diagnostic laparoscopy confirmed a sigmoid perforation with a localized abscess. A sigmoidectomy with end-to-end circular stapled anastomosis was performed, during which the dentures were mobilized retrogradely to enable controlled extraction, leading to a full and rapid recovery.

Conclusion

This case highlights the potential complications and occasional need for surgery due to ingested foreign bodies and the importance of accurate diagnosis and vigilant monitoring in managing these patients.

Introduction

Foreign body ingestion is a frequently observed phenomenon. Once the foreign body has passed the lower esophageal sphincter, it often passes the gastrointestinal tract spontaneously [1]. Early detection of the ingestion is paramount, since unrecognized foreign bodies may lead to severe complications including ileus, perforation of hollow viscus, and erroneous diagnoses. These misdiagnoses may incorrectly attribute the presence of the foreign body with conditions such as malignancies and benign pathology including diverticulitis, increasing morbidity and even mortality rates. [1–4]. The most described ingested foreign bodies are coins and bones [1, 5]. Notably, in 2009, The Lancet published a case report of a 56-year-old woman who accidentally ingested her dentures while eating breakfast. Due to the radiopacity, these dentures were tracked along the gastrointestinal tract until they reached the rectal ampulla without inducing complications. Following this report, conservative management was therefore advised by the authors [6]. Estimates indicate that 10–20% of such cases warrant medical intervention and a gastrointestinal perforation risk of 1% is estimated, primarily occurring at anatomically constricted or angulated areas [2–5, 7].

Case Presentation

A 75-year-old male patient with a history of prostate cancer, for which transurethral resection was performed, presented to the emergency department after allegedly swallowing his dentures earlier that day while consuming a meal. There was no relevant drug or family history. The patient reported no signs of pain, bleeding, or constipation following the ingestion.

Upon physical examination, the vital signs were normal. As expected, there was an absence of the dentures in the oral cavity. The abdomen showed no swelling. Normal peristalsis was auscultated and the abdomen was soft and non-tender during examination. An abdominal plain radiograph examination showed normal findings without the presence of a pneumoperitoneum or foreign bodies (shown in Fig. 1). Considering the asymptomatic status and stable condition of the patient and the non-detection of the dentures on the plain radiograph, it was decided to discharge the patient with detailed instructions for monitoring possible delayed complications.

Fig. 1.

Plain radiograph examination of the abdomen (a) and pelvis (b).

Four days after the initial presentation, the patient sought medical attention complaining of abdominal pain and a cessation of bowel movements for 24 h. Vital signs included a pulse rate of 96 beats per minute, blood pressure of 135/84 mm Hg, and a body temperature of 36.6°C. Physical examination revealed signs of generalized abdominal tenderness with abdominal guarding. Laboratory analysis highlighted an elevated leukocyte count of 18.5 × 10⁹/L and an increased C-reactive protein level of 77 mg/L. A consecutive computed tomography scan elucidated the presence of a foreign object in the sigmoid colon suspicious for a sigmoid perforation (shown in Fig. 2).

Fig. 2.

Computed tomography scan presenting a foreign object in the sigmoid colon surrounded by air suggestive for a perforation displayed on coronal (a) and axial planes (b). The red arrow indicates the dentures, whereas the light blue arrows show the (free) air.

A subsequent colonoscopy located the dentures within the sigmoid colon, approximately 15 cm proximal of the anal verge (shown in Fig. 3a). The dentures were entrapped within the sigmoid colon, making endoscopic removal unachievable, despite repeated efforts of endoscopic extraction. Transanal minimally invasive surgery was ruled out due to the mid-sigmoid location of the dentures.

Fig. 3.

Impaction of dentures within the sigmoid colon upon colonoscopy (a). Intra-abdominal view of laparoscopic surgery with perforation site of sigmoid colon (b), dentures visible at the reopening adjacent to the distal stapler wound (c, d), extraction of dentures with the retrograde anal dilator shown through the incisional wound of the sigmoid (e).

Therefore, an explorative laparoscopy was performed, which exposed sigmoid colon inflammation with infiltration of the epiploic appendices along with the sigmoid perforation and a local abscess (shown in Fig. 3b). Nonetheless, the dentures were not directly observed. The inflammation of the colon hindered both the detection and manipulation of the dentures, suggesting a fixed position adjacent to the perforated intestinal segment. Therefore, a short close-colon segmental resection of the affected sigmoid including the perforation and abscess was performed. A Pfannenstiel incision was used as extraction site. Surprisingly, the dentures were not found in the extracted specimen. After re-establishing a pneumoperitoneum, an anal dilator was inserted with the intention of retrograde mobilization of the dentures. Then, colotomy adjacent to the existing distal staple row in the rectosigmoid stump allowed for the eventual extraction of the dentures. The same Pfannenstiel extraction site was used (shown in Fig. 3c–e). Following removal of the dentures, the rectosigmoid was shortened to create a new vital and intact staple row. Then, a circular end-to-end anastomosis was performed using a circular stapling device. This setup facilitated the creation of a tension-free, end-to-end anastomosis, ensuring the alignment and viability of the colon were maintained. The procedure concluded with a layered closure of the abdominal wall.

Postoperative management included the administration of empirical intravenous antibiotics for 3 days. There was a reduction in abdominal pain, no nausea or vomiting, and a return of appetite. Furthermore, bowel movements recommenced, accompanied by effortless and regular defecation. The patient was discharged at postoperative day four, retaining his intact dentures upon departure. Histopathological examination of the 5-cm resected segment revealed a serositis and the perforation but no underlying pathologies of the sigmoid. At a 5-week follow-up in the outpatient clinic, the patient had made a complete recovery, maintaining a nonrestrictive diet and reporting unproblematic defecation up to four times a day, similar to his preoperative condition.

Discussion

Foreign body ingestion is commonly encountered in clinical practice, necessitating interventions in about 10–20% of the ingestion cases, predominantly in the esophagus. Approximately one percent of all ingestions result in perforations [2–5, 7]. A review of 1,265 cases of ingested foreign bodies in children showed that nearly half involved coins (49%), followed by bones (29%) and other metallic objects (13%) [1].

Dentures are also frequently ingested and should be monitored closely due to their radiolucent nature, which can mimic other conditions like perforated diverticular disease or even malignancies. This is because most dental prostheses are made of polymethyl methacrylate, a radiolucent material that makes radiological tracking difficult [2, 3].

Conservative treatment has been advised specifically for ingested dentures once passed into the duodenum [6]. In a series of 33 cases of surgically treated perforations caused by ingested foreign bodies, only 9.1% were accurately diagnosed preoperatively, highlighting diagnostic challenges. This underscores the importance of vigilant monitoring, whereas interval colonoscopy has been recommended when the foreign body does not traverse the gastrointestinal tract. This might prevent obstruction, impaction, or perforation, since some impacted foreign bodies can cause perforation even many years after ingestion [2, 4, 8].

In the present case, the patient was managed conservatively and discharged without acute symptoms, but close monitoring was advised. For foreign bodies above the stomach, prompt endoscopic removal has been the preferred intervention, with a success rate of approximately 97% [1, 7–9]. However, strategies for extracting foreign bodies in the lower gastrointestinal tract are less clear. Successful endoscopic retrieval of dentures from this area has been reported and is recommended as a minimally invasive option, contingent on the absence of perforation [2, 3, 10, 11].

Rodriguez-Hermosa et al. [5] described nine sigmoid colon perforations due to ingested foreign bodies, requiring surgery. In 67% of these cases, a colostomy was performed, with primary suturing of the defect in the remaining 33%. In 2017, a case was reported involving a distal sigmoid perforation caused by dentures, which was managed with a Hartmann’s procedure [7]. Additionally, Flanagan et al. [4] have described the use of a sigmoidectomy with end-to-end anastomosis for a perforation of the sigmoid, for a similar case. The present case shows that even in the presence of a local abscess, a laparoscopic sigmoidectomy with end-to-end circular stapled anastomosis can be considered as a safe procedure, without subsequent complications.

While conservative management is often recommended, this case underscores the potential complications, endoscopic and surgical challenges, and the measures that might be necessitated for dentures retrieval. Given the radiolucent nature of dentures and their potential to cause delayed and severe complications, timely diagnosis with appropriate intervention is essential. Preventive strategies are also crucial, particularly in elderly or high-risk individuals. Regular dental evaluation of removable and fixed prostheses can help identify poorly fitting or unstable dentures and reduce the risk of accidental ingestion. In patients showing signs of prosthetic instability, timely consultation with a dental professional should be initiated to prevent complications.

Statement of Ethics

In accordance with local and international ethical standards, this case report did not require approval by the Ethics Committee. Written informed consent was obtained from the patient for publication of this case report, including clinical and radiological images. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000549436).

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This study was not supported by any sponsor or funder.

Author Contributions

T.R.W.: preparation of the manuscript and literature analysis/search; on-call resident and assistant of the described sigmoidectomy surgery. S.F.H.: preparation of the manuscript; responsible for clinical aftercare during admission. F.C.B.: literature analysis/search; on-call surgeon and primary surgeon of the described sigmoidectomy surgery. J.P.M.: preparation of the manuscript and literature analysis/search; acquiring informed consent; and follow-up at outpatient clinic after surgery

Funding Statement

This study was not supported by any sponsor or funder.

Data Availability Statement

Clinical data for this case report were obtained from the electronic patient record of the hospital. All relevant information is included in the article. Further inquiries can be directed to the corresponding author.