A rare Case Report of Sigmoid Colon Perforation Due to Accidental Swallowing of Partial Denture

Abstract

Perforation peritonitis is an important cause of generalized peritonitis and pneumoperitoneum. Large bowel perforation due to swallowed artificial denture is extremely rare. Foreign body can be ingested accidentally or in a suicidal attempt. However, ingested foreign body causing sigmoid colon perforation is extremely rare. Complications caused by ingestion of foreign body in gastrointestinal tract include obstruction, perforation, bleeding, or impaction at the sites of physiological narrowing or acute angulation in gastrointestinal tract. We hereby report a case of sigmoid colon perforation due to swallowed partial denture.

Introduction

Sigmoid colon perforation can occur due to many causes like chronic constipation, malignancy, blunt trauma abdomen, stab injury, volvulus, diverticular disease, or rarely by foreign body ingestion. Foreign body swallowing is most commonly seen in the pediatric age group. In adults and elderly, it can occur with psychiatric disorder, alcoholic, mental retardation, or denture wearer [1, 2].

Foreign body swallowing is more common than aspiration especially in the elderly [3]. Majority of foreign bodies that reaches the gastrointestinal tract after ingestion passes spontaneously. However, nonoperative intervention is required in 10–20 % of cases and surgery required only in 1 % or less of the number of cases [4].

This rare case report describes a case of an elderly man with generalized peritonitis with pneumoperitoneum. On exploratory laparotomy, sigmoid colon perforation was identified with protrusion of partial denture through the perforation.

Presentation of Case

A 70-year-old man presented with complaints of pain in the abdomen and abdominal distension since the last 4 days, associated with recurrent vomiting and not passing stool since 2 days. A history of alcoholism and smoking were present. The patient has a known case of hypertension with a history of wearing artificial dentures.

At the time of admission, the patient was conscious, oriented to time, place, and person with a pulse rate of 120 per minute and blood pressure 160 /100 mm of hg. On examination, abdominal distension was present with generalized tenderness and guarding. Radiograph shows minimal free gas under the right dome of the diaphragm suggestive of pneumoperitoneum. Ultrasound scan was suggestive of moderate free fluid in the peritoneal cavity.

Blood investigations shows hemoglobin was 11.5 g/dl, WBC count was 18,000/cmm, and platelet count was 2.5 lakh/cmm. Blood sugar was 98 mg/dl, blood urea was 88 mg/dl, and serum creatinine was 2.1 mg/dl. Urine examination was normal.

The decision of exploratory laparotomy was taken with diagnosis of perforation peritonitis. On exploration, around 600 ml feco-purulent fluid was drained out. The stomach and small bowel were looked for any perforation but revealed no pathology. The large bowel was looked carefully and a protruding foreign body was found through the perforation in the sigmoid colon. Only part of the foreign body was visible through the defect; the rest of the portion was inside the lumen of the sigmoid colon. The foreign body was removed and identified as partial artificial denture. Wash with normal saline was done, and primary repair of the defect was done after freshening of the margins of perforation with placement of an abdominal drain. The patient recovered well in postoperative days and discharged on the ninth day (Figs. 1 and 2).

Fig. 1.

Intraoperative photographs showing sigmoid colon perforation with protruding denture

Fig. 2.

Intraoperative photographs of sigmoid perforation with denture

Discussion

Gastrointestinal tract perforation is the most common cause of generalized peritonitis and pneumoperitoneum. Among these cases, majority of them are due to peptic perforation, ileal perforation in enteric fever, or small bowel perforation in blunt trauma of the abdomen. Large bowel perforation is seen in a few cases only like diverticular disease, carcinoma, obstruction, and rarely due to trauma. A foreign body can be ingested accidentally or in a suicidal attempt. However, an ingested foreign body causing sigmoid colon perforation is extremely rare. Complications caused by ingestion of a foreign body in the gastrointestinal tract include obstruction, perforation, bleeding, or impaction at the sites of physiological narrowing or acute angulation in the gastrointestinal tract [5].

Symptoms and sign occur according to the site of the foreign body in the gastrointestinal tract. Undiagnosed swallowed denture presents with late complications like fistula formation, abscess, sigmoid colon perforation, extraluminal migration, or death [6].

Sites of perforation after ingestion of sharp foreign objects include the duodeno-jejunal junction, ileocecal junction, colonic flexure, diverticula, and sigmoid colon. The mean time of occurrence of perforation after ingestion of a sharp foreign object is 10.4 days [7].

Investigations like radiograph, sonography, and computated tomography are important tools in the diagnosis of foreign body in the gastrointestinal tract. Foreign body detection depends on its shape, constituent material, dimensions, and position [8].

Once diagnosed as perforation peritonitis due to an ingested foreign object preoperatively, then laparotomy is required with removal of the foreign body and resection of the involved segment or primary repair of the defect is the treatment of choice. In our case, the patient was admitted as a case of generalized peritonitis with pneumoperitoneum without any history of foreign body ingestion. On exploration, sigmoid colon perforation was detected due to partial denture which is a rare finding.

Conclusion

The morbidity and mortality related to foreign body ingestion is dependent on the nature of the object, general condition of the patient, complication caused by the foreign body, and treatment modality. Elderly and noncooperative patient may not provide history of foreign body ingestion before the complication occurs.