Foriegn bodies in the abdomen

34 Pages·2014·3.87 MB·English

Foriegn bodies in the abdomen - common, not so common
and the exotic
Poster No.: C-1458
Congress: ECR 2014
Type: Educational Exhibit
Authors: 1 2 3 1
E. C. nandury , S. Boppana , B. V. Mallula ; Hyderabad/IN,
2 3
Hyderabad, AP/IN, Hyderabad, Andhra Pradesh/IN
Keywords: Foreign bodies, Eating disorders, Localisation, Diagnostic
procedure, Contrast agent-oral, Plain radiographic studies, Digital
radiography, CT, Gastrointestinal tract, Colon, Abdomen
DOI: 10.1594/ecr2014/C-1458
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Page 1 of 34
Learning objectives
1. Identify various foreign bodies on imaging modalities, especially radiographs and CT
scans.
2. Detect complications at imaging
Background
Foreign bodies are rare, at times beguiling, may masquerade infections or neoplasms and
can cause serious complications. Young children, emotionally labile persons, alcoholics,
drug intoxicated, people with poor visual acuity and rapid eaters are predisposed.
Foreign bodies may be ingested (Fig 1), inserted into body cavities or may enter the body
by penetrating injury (Fig 2) or iatrogenically. Foreign body ingestions are commonly seen
in young children and mentally challenged adults. Most ingested foreign bodies traverse
the gastrointestinal tract uneventfully. However sharp objects like needles or open safety
pins may get impacted at normal points of intestinal narrowing such as duodenal loop,
duodenojejunal junction or terminal ileum. Impaction of sharp objects or larger blunt
objects may occur at areas of bowel strictures. The complications may include bowel
perforation, obstruction, peritonitis, abscess formation and fistula.
Radiographically foreign bodies can be opaque (Fig 3) or non-opaque. Radiopaque
materials include glass, most metals, most animal bones, certain types of foods, certain
type fish bones, sand, medications and certain poisons.
Most types of food, most types of medicines, most types of wood, most aluminum objects
and most types of plastics are non-opaque.
In case of suspected metallic/opaque foreign bodies, plain radiographs are the initial
modality of investigation. Serial radiographs may be performed to monitor the passage of
ingested opaque objects through the gastrointestinal tract. Radiographs may also reveal
complications of foreign body ingestion such as intestinal obstruction and perforation. In
children or mentally unstable adults with a history of foreign body ingestion, it is essential
to image from the base of the skull to the rectum for detection and accurate localization.
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CT scans are usually performed for accurate localisation (Fig 4) and to assess
complications like peritonitis (Fig 5), obstruction, abscess formation, fistula formation and
in those situations where plain radiographs are non-contributory.
Care should be taken when performing MRI scans in patients with a history of foreign
body ingestion or foreign body injury as they can cause significant image degradation
but more importantly they can be hazardous (Fig 6).
Images for this section:
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Fig. 1: Swallowed key. Abdominal radiograph in an 8 month old female child reveals a
swallowed key in the midline pelvis overlying the L5-S1 vertebrae.The key passed off
uneventfully
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Fig. 2: Needle in the gastric antrum. Axial contrast enhanced CT section in a 65 year old
female presenting with severe right hypochondriac pain reveals a hyperdense metallic
needle perforating the gastric antrum and extending up to the anterior abdominal wall.
The patient denied history of ingestion/insertion and was treated surgically.
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Fig. 3: Swallowed glass bangle piece. Abdominal radiograph in 21 year old female with
history of accidental ingestion of a bangle piece reveals a small linear radiopaque density
in the mid descending colon, which passed off uneventfully.
Fig. 4: Metallic foreign body in the perirectal region. Axial radiograph of the pelvis and
CT scan in a 65-year-old male reveal a small incidental metallic foreign body in the
right anterior perirectal region abutting the right seminal vesicle. There was no history
of foreign body injury.
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Fig. 5: Retained surgical sponge. 25-year-old female with a past history of cesarean
section presenting with severe pain abdomen. CT topogram reveals a large mottled
density in the right lumbar/iliac fossa regions (red circle). Contrast-enhanced axial CT
sections reveal a large soft tissue density with mottled air lucencies in the right lumbar
region suggestive of a retained surgical sponge(arrow). There is also large amount of
intraperitoneal fluid with pneumoperitoneum and peritoneal enhancement suggestive of
peritonitis.
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Fig. 6: Incidental detection of a metallic foreign body in the small bowel mesentery on
MRCP examination in a 55-year-old male with cholelithiasis. MRCP image reveals a
linear transverse filling defect in the distal CBD extending into the adjacent soft tissues
due to a susceptibility artifact. Coronal T2 HASTE MRI reveals large susceptibility artifact
in the region of the duodenum. A subsequent abdominal radiograph and axial CT sections
reveal a linear metallic foreign body in the small bowel mesentery on the right side. Patient
denies any significant past history of foreign body injury.
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Findings and procedure details
Foreign bodies are relatively uncommon in clinical practice, but can cause serious
difficulty in diagnosis and treatment. They can be ingested, inserted into body cavities
by injury or iatrogenic procedures.
Most ingested foreign bodies traverse the gastrointestinal tract without major problem
(Fig 7, Fig 8 & Fig 9). Foreign bodies can be multiple and finding one should prompt a
thorough search for others.
Most animal bones, glass and metallic foreign bodies are radioopaque with the exception
of aluminum. Most plastic, wood and fish bones are non-opaque.
Foreign body ingestion is common in children (Fig 10) and mentally challenged adults
(Fig 11 & Fig 12). The common objects ingested include coins, watch batteries, needles,
safety pins and razor blades. Most of the ingested foreign bodies pass uneventfully
through the gastrointestinal tract.
Watch batteries are commonly ingested by young children and usually pass without
complications (Fig 13).
However they can cause serious complications when the capsule breaks causing the
alkaline corrosive contents to spill into the intestine leading to perforation, septicaemia
and even death.
Pica is characterized by an appetite for substances largely non-nutritive, such as ice,
clay, chalk, dirt, or sand and is usually seen in children and women (Fig 14). Causes
include habits from a cultural tradition, acquired taste or a neurological mechanism such
as an iron deficiency or chemical imbalance.
Sharp objects may not pass easily and can cause complications such as perforation or
obstruction (Fig 15).
Perforation of the gastrointestinal tract is seen in less than 1% of patients with foreign
body ingestion. The most common sites include the ileocecal region, appendix and
Meckel's diverticulum.
Majority of the fish bone ingestions pass off uneventfully. Fish bone perforation in the
abdomen and pelvis, distal to the esophagus is uncommon and occurs in less than 1
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