The odd fate of a chicken dinner

Description

A 75-year-old woman presented with a 3-day history of right iliac fossa (RIF) pain and vomiting. On examination she looked well, had normal observations, but exquisite tenderness in the RIF. Her medical history included open anterior resection for sigmoid adenocarcinoma, adhesiolysis and bilateral hip arthroplasties. CT abdomen/pelvis reported a metallic streak artefact related to the bilateral hip arthroplasties in the RIF, no evidence of perforation and faecal loading’. She was initially managed conservatively. The persistence and intensity of her pain were disproportionate to the CT findings, and imaging review highlighted that the previously reported metallic streak could be a foreign body (figure 1). Ultrasound confirmed a linear density within the caecum extending through the wall with localised free fluid and gas. At laparotomy a 5 cm chicken bone was found protruding through the caecal wall; it was removed via enterotomy (figure 2). The patient made a full recovery. Diagnosis of foreign body bowel perforation requires a high degree of suspicion. Most foreign bodies pass through the gastrointestinal tract without consequence; however fish bones, chicken bones, toothpicks and cocktail sticks have been known to cause perforation.^1–3 Most people do not remember ingesting the object.¹ Presenting features can include: peritonitis, obstruction, per rectal bleeding, abscess or enteric fistula formation.^1–3 Risk factors include extremes of age, dentures, alcoholism, mental illness and underlying bowel pathology such as diverticular disease or intestinal strictures.¹ Perforation occurs most often at points of narrowing or angulation and the presence of adhesions may have contributed in this case.

Figure 1.

Axial CT showing the chicken bone protruding through the caecal wall (arrow).

Figure 2.

A) Intraoperative image of the chicken bone protruding through the caecal wall (arrow). B) Chicken bone.

Learning points.

• Be aware of foreign body perforation as a differential diagnosis in patients presenting with an acute abdomen, particularly in those who are at the extremes of age, wear dentures, have a high alcohol intake, mental illness, or a medical history of bowel pathology.

• Patients will commonly not recall ingesting the foreign body so do not rely on this as part of the history.

• CT is considered to be the most useful imaging to determine the preoperative diagnosis and associated complications, however as shown in this case ultrasound can also be a valuable investigation.