Disorders of an organ not usually found in the right iliac fossa, such as the sigmoid colon, are an uncommon cause of right iliac fossa pain.

We present a case of right iliac fossa pain caused by a sigmoid perforation due to involuntary ingestion of a rabbit bone, and describe the main features of this condition

Corazza, F.

Grassi, Antonio

Iusco, Domenico Rosario

Jannaci, Marcello

Virzì, Salvatore

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IntroductionVarious foreign bodies cause gastrointestinal perfo-rations (1). They are not uncommon in the elderly (den-ture wearers), alcoholics, children and people withlearning difficulties. Most patients do not remember swal-lowing the foreign body, which is discovered either onimaging or more frequently during surgery. Symptomsvary with the site of the perforation, and the clinical pre-sentation can mimic different conditions, such as acu-te appendicitis, diverticulitis, cecal tumors and perforatedpeptic ulcer. We report a case in which a sigmoid perforation dueto the ingestion of a rabbit bone presented with symp-toms and signs of acute appendicitis, and review the li-terature concerning this issue.Case reportA 55 year-old woman came to the Emergency Room with rightlower quadrant abdominal pain which had started 12 hours earlier.Her medical history included dilated cardiomyopathy and hospita-lization (10 years previously) for pelvic inflammatory disease. She hada temperature of 38 °C and the pain was associated with nausea andvomiting. Laboratory tests revealed leukocytosis (14.79 x 103/mm3)with marked neutrophilia (86.6%) and an elevated C-reactive pro-tein level (1.4 mg/dL).The patient was overweight. Her abdomen was tender in the ri-ght iliac fossa and hypogastrium, and a rebound tenderness was pre-sent in the right iliac fossa. No bowel sound was present. Rectal ex-ploration was negative, although particularly painful. A gynecolo-gical examination was requested in the Emergency Room due to thepatient’s medical history. Transvaginal ultrasound showed only a mo-derate amount of fluid in the pelvis and in the right iliac fossa, andno gynecological disease was detected. A plain abdominal X-ray wasnegative. Abdominal ultrasound confirmed the free fluid in the pel-vis and in the right iliac fossa.The patient was admitted to the operating room with a diagnosisof acute abdomen, and emergency surgery was scheduled. A diagnosticlaparoscopy was not performed due to the increased anesthesiologicalSUMMARY: Unusual cause of right iliac fossa pain: sigmoid perfo-ration due to ingested rabbit bone. Case report. D.R. IUSCO, M. JANNACI, A. GRASSI, F. CORAZZA, S. VIRZÌDisorders of an organ not usually found in the right iliac fossa, su-ch as the sigmoid colon, are an uncommon cause of right iliac fossapain. We present a case of right iliac fossa pain caused by a sigmoid perfo-ration due to involuntary ingestion of a rabbit bone, and describe themain features of this condition. RIASSUNTO: Una causa insolita di dolore in fossa iliaca destra: perfo-razione del sigma da ingestione di osso di coniglio. Case report.D.R. IUSCO, M. JANNACI, A. GRASSI, F. CORAZZA, S. VIRZÌPatologie di organi non localizzati tipicamente in fossa iliaca de-stra, come il sigma, sono causa insolita di dolore in tale zona.Presentiamo un caso di dolore in fossa iliaca destra causato da unaperforazione del sigma dovuta all’ingestione involontaria di un osso diconiglio e descriviamo le principali caratteristiche di questo quadro pa-tologico.KEY WORDS: Sigmoid perforation - Rabbit bone - Right abdominal pain.Perforazione del sigma - Osso di coniglio - Dolore fossa iliaca destra.Unusual cause of right iliac fossa pain: sigmoid perforation due to ingested rabbit bone. Case report D.R. IUSCO1, M. JANNACI1, A. GRASSI1, F. CORAZZA2, S. VIRZÌ1G Chir Vol. 32 - n. 10 - pp. 421-423October 2011421Bentivoglio Hospital, Bentivoglio (Bo), Italy1 Department of Surgery2 Maternal and Child Department,Gynecological Surgery Unit© Copyright 2011, CIC  Edizioni Internazionali, Roma0457 5 Unusual_Iusco:-  29-09-2011  8:26  Pagina 421422D.R. Iusco et al.risk associated with the dilated cardiomyopathy, and as the main cli-nical suspicion was acute appendicitis the operation began with a Mc-Burney incision. Laparotomy revealed a large amount of purulentliquid, moderately inflamed appendix, and sigmoid colon with a di-verticulum perforated by a bone (Fig. 1). The patient underwent mid-line laparotomy, Hartmann procedure and appendectomy. Pathologicalexamination of the specimen showed peritonitis and sigmoid di-verticulitis with perforation. Examination of the appendix showedchronic inflammation with fibrinous periappendicitis.The postoperative course was uneventful and the patient was di-scharged 7 days after surgery. When questioned again she remem-bered having eaten rabbit meat four days before the hospital admission.Three months after the Hartmann procedure she was reoperated torestore intestinal continuity. She recovered well from the second ope-ration and is now fit and healthy.DiscussionAcute appendicitis is the leading cause of right lowerquadrant (RLQ) abdominal pain. It is well known thatseveral diseases, such as ileitis terminalis, cecal tumor, andsolitary cecal diverticulum, can mimic appendicitis. Gy-necological diseases such as acute salpingitis may also cau-se RLQ pain (2). It can also be due to an organ not usual-ly located in the right iliac fossa, such as the sigmoid co-lon, whose extreme mobility can cause it to move intothe right iliac fossa, giving rise to symptoms correlatedwith acute inflammation. The most common sigmoiddisease that can cause RLQ pain is diverticulitis, whilesigmoid perforation due to cancer or a foreign body isless frequent (3).The most common objects accidentally swallowed aredentures, fish or chicken bones, and toothpicks. Thesenormally pass through the gastrointestinal tract withoutany consequences (4), with perforation requiring surgeryoccurring in only 5% of cases. A preoperative diagno-sis of foreign body ingestion is often uncertain; volun-tary swallowing of one or more foreign bodies is relati-vely rare and is normally done by prisoners and attemptedsuicides, whereas most patients do not realize they haveswallowed a foreign body.Gastrointestinal (GI) perforations by a foreign bodyare rarely diagnosed preoperatively because the clinicalsymptoms are usually non-specific and mimic other sur-gical conditions, such as appendicitis, as in our case, ordiverticulitis (5). There is a greater risk of perforation inthe elderly and people wearing orthodontic appliancesand dentures, since these devices cover the most tactilearea of the palate and therefore swallowing of the forei-gn body goes unnoticed. There is also a high risk of perfo-ration in cases of previous bowel disease and in alcoho-lic and psychiatric patients. Overeating and rapid eatingmay be contributing factors to the ingestion of small bo-nes from chicken or other animals. The mean time from ingestion to any perforation is10.4 days (6); in our case the symptoms developed 4 daysafter ingestion. The risk of perforation is related to thelength and the sharpness of the object (7). Most perfo-rations occur at the narrowing and angulations of the GItract (8) (i.e., ileocecal valve and rectosigmoid junction).Earlier case reports of traumatic perforation of the sig-moid colon stressed the existence of a background con-dition such as diverticular disease, cancer or fistula (9,10).In our case, the rabbit bone perforated the sigmoid co-lon, which had been affected by diverticular disease. Cli-nically, our patient presented acute abdomen with su-spected appendicitis, even though the perforation involvedthe sigmoid colon. Assa et al. described the sigmoid co-lon as an often redundant organ with a tendency to mi-grate to the right side of the abdomen, as in our case (3). The definitive diagnosis in this patient was reachedby surgery. This is in accordance with literature reports,in which the diagnosis of intestinal perforation by foreignbody was reached during laparotomy in more than 90%of cases (6,11-12). All cases involved abdominal conta-mination and 66.7% had diffuse peritonitis (6). Laparoscopy has been widely accepted among sur-geons for the diagnosis and management of acute ab-dominal conditions. In our case it was not possible touse this procedure due to the patient’s past medical hi-story, so we missed the opportunity for a preoperativediagnosis.Although imaging can be nonspecific, the identifi-cation of a small bone with an associated mass or ex-traluminal collection of gas in patients with clinical signof peritonitis, mechanical bowel obstruction, or pneu-moperitoneum strongly suggests the diagnosis (8,13-14).Ripolles et al. reviewed the diseases that can simulate anFig. 1 - Intraoperative finding of a small animal bone perforating the sigma.0457 5 Unusual_Iusco:-  29-09-2011  8:26  Pagina 422acute appendicitis on ultrasound, concluding that sig-moid inflammation and perforation generally are verydifferent to acute appendicitis. However, in cases in whi-ch an inflamed right sigmoid colon presents with RLQabdominal pain, mural thickening of the sigmoid colonis often seen. In doubtful cases, a CT scan will usuallyconfirm the diagnosis and will also demonstrate the pre-sence of any abscess (15).Depending on the extent of the perforation and itsanatomical site, as well as on the presence of diffuse orcircumscribed peritonitis, the treatment of foreignbody perforation will vary from simple suturing, withor without a protective colostomy, to the Hartmann pro-cedure (16).ConclusionWe described a sigmoid perforation due to an inge-sted rabbit bone in a case in which the clinical and la-boratory findings, associated with doubtful imaging andthe inability to perform an explorative laparoscopy, ledus to misdiagnosis. This situation is very common, as itis often difficult to distinguish clinically among the patho-logic conditions that may cause RLQ pain. It should beborne in mind, however, that the incidence of acute ap-pendicitis decreases with age, so a non-appendiceal di-sease should be suspected in an elderly patient presen-ting with right iliac fossa pain; in such cases a diagno-stic laparoscopy, where possible, is always recommended.423Unusual cause of right fossa iliac pain: sigmoid perforation due to ingested rabbit bone. Case report1. Schwartz GF, Polsky HS. Ingested foreign bodies of the gas-trointestinal tract. Am Surg 1976;42(4):236-8.2. Kumar S, Fitzmaurice GJ, O'Donnell ME, Brown R. Acute rightiliac fossa pain: not always appendicitis or a caecal tumour: twocase reports. Cases J 2009;2(1):88.3. Assa J, Zoireff L, Iuchtman M. Perforation of the sigmoid colonsimulating acute appendicitis. Isr J Med Sci 1980;16(9-10):646-8.4. Ali W, Khan M. Intestinal perforation due to an ingested for-eign body. J Coll Physicians Surg Pak 2007;17(4):234-5.5. Yao CC, Yang CC, Liew SC, Lin CS. Small bowel perforationcaused by a sharp bone: laparoscopic diagnosis and treatment.Surg Laparosc Endosc Percutan Tech 1999;9(3):226-7.6. Rodríguez-Hermosa JI, Codina-Cazador A, Sirvent JM, MartínA, Gironès J, Garsot E. Surgically treated perforations of the gas-trointestinal tract caused by ingested foreign bodies. ColorectalDis 2008;10(7):701-7.7. Sarliève P, Delabrousse E, Michalakis D, Robert A, Guichard G,Kastler B. Multidetector ct diagnosis of jejunal perforation bya chicken bone. JBR-BTR 2004;87(6):294-5.8. Singh RP, Gardner JA. Perforation of the sigmoid colon by swal-lowed chicken bone: case reports and review of literature. Int Surg1981;66(2):181-3.9. Hewett PJ, Young JF. Toothpick injuries to the gastrointestinaltract. Aust N Z J Surg 1991;61(1):35-37.10. McManus JE. Perforation of intestine by ingested foreign bod-ies: report of two cases and review of literature. Am J Surg1941;53:393-402.11. Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL,Wong WK. Perforation of the gastrointestinal tract secondary toingestion of foreign bodies. World J Surg 2006;30(3):372-7.12. Pinero Madrona A, Fernández Hernández JA, Carrasco Prats M,Riquelme Riquelme J, Parrila Paricio P. Intestinal perforation byforeign bodies Eur J Surg 2000;166(4):307-9.13. Rasheed AA, Deshpande V, Slanetz PJ. Colonic perforation byingested chicken bone. AJR Am J Roentgenol 2001;176(1):152.14. Maglinte DD, Taylor SD, Ng AC. Gastrointestinal perforationby chicken bones Radiology 1979;130(3):597-9.15. Ripollés T, Martinez-Perez MJ, Morote V, Solaz J. Diseases thatsimulate acute appendicitis on ultrasound. Br J Radiol1998;71(841):94-8.16. Fama R, Di Natale I, Padoan L, Donadi M, Di Natale R. Per-foration of the colon by a foreign body. Chir Ital 1993;45(1-6):118-123.References0457 5 Unusual_Iusco:-  29-09-2011  8:26  Pagina 423

Unusual cause of right iliac fossa pain: sigmoid perforation due to ingested rabbit bone. Case report

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Unusual cause of right iliac fossa pain: sigmoid perforation due to ingested rabbit bone. Case report

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