Toddler With Fever and Abdominal Tenderness
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Answer
Appendiceal perforation by a foreign body (a
pin): A foreign body was easily apparent on
conventional abdominal radiographs in the right
lower quadrant. CT scanning of the abdomen and
pelvis revealed a radiopaque pin and a
multiloculated fluid collection at the L5 level.
The prominent bowel loops superior to the pin likely represent focal ileus.
On laparotomy, drainage and excision of an
intra-abdominal abscess, as well as appendectomy
and removal of the foreign body, were performed.
The appendix was 4.3 cm, and a metallic pin was
found piercing the bowel wall (see Image 4).
Histology revealed acute serositis with
fibrinopurulent exudates in the lumen and on the
serosal surface of the appendix.
Ingestion of foreign bodies is relatively common
among pediatric patients, who account for
approximately 80% of ingestions. Most objects
pass spontaneously, and only 1% of all
foreign-body ingestions require surgical
intervention. Among adults, foreign-body
ingestions most frequently occur in those with
psychiatric disease or with potential secondary gain.
Management depends on the type of object
ingested. The objects most commonly ingested are
coins, buttons, parts of small toys, pins and
thumbtacks, and disk-shaped batteries. For known
ingestion of nontoxic, smooth, or small objects,
management is conservative, as approximately
80-90% of these foreign bodies spontaneously pass
though the GI tract without harm.
Initial radiographic localization and serial
abdominal radiography should be performed every
24-48 hours to monitor progression of the object
until it is passed in stool. Foreign bodies may
lodge at any site in the GI tract but most often
lodge at anatomic sphincters or areas of
narrowing, acute angulation, or previous surgery,
where they tend to cause obstruction or
perforation. The esophagus has several sites of
potential obstruction, and perforation at these
sites is a particular concern because rates of
related morbidity and mortality are high.
Complications include mediastinitis, lung
abscess, pneumothorax, and pericarditis.
Approximately 90% of foreign bodies that reach
the stomach pass through the remaining GI tract.
Most smooth objects pass with normal bowel transit time.
Because of the high risk of intestinal
perforation, urgent intervention is indicated for
all patients who have ingested a long, thin,
sharp, or stiff foreign body that fails to
progress through the GI tract regardless of their
clinical signs and symptoms. Localization with
radiography should be followed by an immediate
attempt to remove the object by means of
endoscopy when possible. Emergency laparotomy is
indicated if the patient develops abdominal pain
or tenderness; fever; or other clinical evidence
of perforation, hemorrhage, or obstruction.
Cathartic agents are contraindicated.
Foreign bodies rarely cause complications in the
small bowel and colon because they are surrounded
by stool and directed to the center of the lumen.
In the rare case when the object becomes static
in the right lower quadrant (terminal ileum,
cecum, or appendix), as in this patient, removal
by means of colonoscopy should be considered.
Other options include laparotomy or laparoscopic
removal under fluoroscopic guidance.
Reported complications of foreign bodies in the
distal GI tract include obstruction, abscess
formation, peritonitis, adhesions, fistula
formation, perforation, and appendicitis. Long,
slender, and sharp objects are most likely to
injure the mucosa and cause inflammation and
perforation, whereas smooth objects lodged in the
appendix tend to cause obstruction, leading to
acute appendicitis, rupture, and abscess
formation. Objects heavier than bowel fluid tend
to rest in the cecum and gravitate to its most
dependent portions. The normal appendix can empty
its contents by means of peristalsis; however,
the presence of a foreign body, adhesions, or
inflammatory infiltrate can hinder its emptying.
For more information on foreign body
perforations, see the eMedicine articles
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/emerg/topic379.htm%5Etarget=%5E_blank%5E>Pediatrics,
Foreign Body Ingestion and
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/emerg/topic897.htm%5Etarget=%5E_blank%5E>Foreign
Bodies, Gastrointestinal (within the Emergency
Medicine specialty) and
<http://knowledge.emedicine.com//splash/shared/pub/xrotw/%5Ehttp://www.emedicine.com/ped/topic2777.htm%5Etarget=%5E_blank%5E>Gastrointestinal
Foreign Bodies (within the Pediatrics specialty).
References
* Balch CM, Silver D. Foreign bodies in the
appendix. Report of eight cases and review of the
literature. Arch Surg 1971 Jan;102(1):14-20.
* Cheng W, Tam PK. Foreign-body ingestion in
children: experience with 1,265 cases. J Pediatr
Surg 1999 Oct;34(10):1472-6. Collins DC. 71,000
Human appendix specimens. A final report
summarizing forty years' study. Am J Proctol 1963 Dec;14:265-81.
* Klingler PJ, Seelig MH, DeVault KR, et al.
Ingested foreign bodies within the appendix: a
100-year review of the literature. Dig Dis 1998 Sep-Oct;16(5):308-14.
* Klinger PJ, Smith SL, Abendstein BJ, et al.
Management of ingested foreign bodies within the
appendix: a case report with review of the
literature. Am J Gastroenterol 1997 Dec;92(12):2295-8.
* Rajagopal A, Martin J, Matthai J. Ingested
needles in a 3-month-old infant. J Pediatr Surg 2001 Sep;36(9):1450-1.
* Spitz L. Management of ingested foreign
bodies in childhood. Br Med J 1971 Nov 20;4(785):469-72.
BACKGROUND
A 14-month-old boy is brought to the emergency
department by his parents for an evaluation of
persistent fever, vomiting, and diarrhea that has
lasted for 3 days. The mother states that her
son's pediatrician examined him 2 days ago for a
"viral illness." However, the child has appeared
increasingly ill since then. He has become
irritable, and he has been minimally active and
feeding poorly. He has had normal stool output
and appearance and his normal number of wet
diapers. The parents deny observing a runny nose,
cough, and wheezing or stridor. The child lives
at home with his parents, he is not in day care,
and he has had no contacts with people who are sick.
On physical examination, the boy is crying,
fussy, and poorly consoled. His vital signs
include a rectal temperature of 101°F, a
respiratory rate of 32 breaths per minute, a
blood pressure of 98/56 mm Hg, and a heart rate
of 168 beats per minute. His oxygen saturation is
100% while he is breathing room air. The
patient's weight is 10 kg. Palpation reveals
diffuse abdominal tenderness without rigidity or
guarding. The patient has diffusely hypoactive
bowel sounds. His stool is negative for occult
blood. The rest of the physical findings are otherwise unremarkable.
Abdominal conventional radiography and CT are
performed (see Images). Laboratory investigation
reveals the following results: WBC count 19.4 X
109/L with a predominance of neutrophils,
hemoglobin 8.4 g/dL, hematocrit 26.6%, platelets
310 X 109/L, Na 136 mmol/L, K 3.8 mmol/L, Cl 105
mmol/L, CO2 20 mmol/L, BUN 6 mmol/L, creatinine
17.7 µmol/L (0.2 mg/dL), and glucose 4.1 mmol/L
(73 mg/dL). Urinalysis shows trace ketones, but
the results are otherwise normal.
What is the diagnosis?
Hint
The patient's symptoms developed approximately 2
days after the mother dropped a box of pins on the carpet at home.
Author: Anusuya Mokashi, Medical Student, New York Medical College, Valhalla
Justin Weir, Medical Student, New York Medical College, Valhalla
Margaret D. Smith, MD, Program Director,
Department of Medicine, St. Vincent Catholic
Medical Centers (SVCMC) St. Vincent's Hospital
Manhattan, Senior Associate Dean and Associate
Professor of Clinical Medicine, New York Medical
College, St. Vincent's Hospital Manhattan
eMedicine Editor: Erik Schraga, MD, UCLA - Olive
View Medical Center Residency, Department of
Emergency Medicine, Olive View - UCLA Medical Center
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