British Journal of Radiology (2006) 79, 173-174
© 2006 British Institute of Radiology
doi: 10.1259/bjr/85745053
Ingested foreign body mimicking an appendicolith in a child
V Moorjani, MD
C Wong, FRANZCR
and
A Lam, FRANCZR
Department of Imaging, The Childrens Hospital at Westmead, Locked bag 4001, Westmead, Sydney, NSW 2145, Australia
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Abstract
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We describe an unusual case of a child who had ingested sand and stones and presented with signs and symptoms suggestive of appendicitis. Plain radiographs revealed calcific opacities in the right iliac fossa simulating appendicoliths. At surgery and histopathology a small sealed off perforation of the terminal ileum with hard concretions in the wall was observed.
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Case report
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An 18-month-old male child was referred to our hospital with nausea, vomiting abdominal pain and fever lasting 3 days. On examination the child had a non-distended abdomen and generalized peritonism. An abdominal radiograph revealed two radiopaque foreign bodies in the right iliac fossa with distension of proximal loops of bowel (Figure 1
). Mobility of the calcific opacities was seen on the radiographs taken prior to admission and after being admitted to the hospital (Figure 2). An ultrasound examination demonstrated two echogenic areas in the right iliac fossa which appeared to be in a non-compressible inflamed loop of bowel (Figure 3). The bowel wall was thickened and the adjacent mesentery adherent to it. There was minimal free fluid in the peritoneal cavity. A provisional diagnosis of acute appendicitis with appendicoliths was entertained, a comment was made to the referring surgeon that the overall appearance was unusual for acute appendicitis. The child underwent an exploratory laparotomy.
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Figure 1. Plain supine abdominal radiographs. Two calcific opacities are seen in the right iliac fossa.
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Figure 3. Ultrasound of the right iliac fossa. A calcific opacity is seen in the lumen of the bowel. The walls of the loop are thickened.
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At operation the terminal ileum was severely inflamed with a small sealed perforation. The appendix looked normal. The ileal segment and the appendix were resected and an ileocolic anastomosis performed. Histopathology revealed ulcerations with full thickness necrosis. There was hard debris within the intestinal wall. No intrinsic inflammation was seen in the appendix but the serosa and subserosa were actively inflamed with some purulent exudate on the surface.
On further questioning the parents, a history of the child ingesting sand and stones was elicited. A calcific opacity was still present on the repeat radiograph (Figure 4). The child was discharged and parents were asked to follow up and to check the stools daily for foreign bodies.
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Discussion
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Depending on their nature, ingested foreign bodies may have an uneventful course or be impacted in the gastrointestinal tract. Most of the foreign bodies pass through the gastrointestinal tract within a week [1]. The reported incidence of bowel perforation is less than 1%, the objects being pointed or sharp in most cases like tooth picks, sewing needles, dental plates, fish bones and chicken bones [1]. The most common sites of perforation are the ileocecal junction and the rectosigmoid region. There has been a single case report of plum pits in the terminal ileum. This resulted in an inflammatory conglomerate tumour proximal to the ileocecal valve and presented years later with intestinal bleeding [2]. Segal [3] reported a case of ingestion of soft drink bottle top and stones which resulted in chronic ileitis. Sclerosing encapsulated peritonitis also called as calcifying peritonitis appears as dilated bowel loops, air fluid levels and peritoneal calcifications on plain films. Ultrasound reveals dilated fixed bowel loops matted together and tethered posteriorly, intraperitoneal echogenic strands and an echogenic sandwich appearance of the membrane.
The child in our case had ingested stones and sand. The wall of the terminal ileum was ulcerated either due the direct action of the stones or due to the inflammation or both with subsequent necrosis and perforation, and the sand and small stones spilling out into the peritoneum. The calcific opacities were not observed on histology as one of the calcifications must have been crushed by the microtome and the other could have moved out of the operative field.
To conclude a common cause of a calcific opacity in the right iliac fossa in a child who presents with signs and symptoms of appendicitis would be an appendicolith. The other differential diagnosis of a calcific opacity in the right iliac fossa would include calculus in a vesical diverticula, enterolith, phlebolith in a pelvic vein, ectopic gallstone, calcification within a teratoma and calcification in a mesenteric lymph node. A giant appendicolith measuring 3 cm has been reported [4]. Calculi located in urinary bladder diverticula have a dumb-bell shape with one end lodged in the diverticulum and the other projecting into the lumen of the bladder. In a phlebolith usually a central lucency can be seen. An ectopic gallstone was ruled out since the gallbladder was normal on ultrasound. The classic ultrasound appearance of teratoma is a prominent cystic component and at least one contained mural nodule that is often echogenic as a result of contained fat, hair, sebum or calcium. The calcific opacity in our case was located in a bowel loop on ultrasound.
Retrospective review of the radiographs revealed that the calcification was very dense in our case and did not have the typical laminated appearance of an appendicolith. The change in the position of the calcifications on serial radiographs would also be a pointer against an appendicolith. Rarely a foreign body may simulate appendicitis with gut inflammation and a radiopacity should be considered in the differential diagnosis.
Received for publication December 2, 2004.
Revision received April 10, 2005.
Accepted for publication May 23, 2005.
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References
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- Chintamani, Singhal V, Lubhana P, Durkhere R, Shabnam B. Liver abscess secondary to a broken needle migration: a case report. BMC Surgery 2003;3:8–13.
- Lucker C, Schulte GA, Moldenhauertt. Plum pits in the terminal ileum. Rontgenblatter 1987;40:191–2.[Medline]
- Segal I, Nouri MA, Hamliton DG, Ou Tim L, Giraud RM, Mirwis J, et al. Foreign-body ileitis: a case report. S Afr Med J 1980;58:421–2.[Medline]
- Devalia H, Dhamdhere M, Horner J. A giant appendicolith: miscellaneous case 2947. In: Gastrointestinal Imaging 2004. Available via EURORAD. http://www.eurorad.org/case [Accessed 5 February 2004]
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Abstract
Case report
