
==== Front
Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01065-4
10.1016/j.ijscr.2024.110284
110284
Case Report
Ileal perforation peritonitis secondary to accidental ingestion of a chicken bone: A case report
Panday Bijay a
Bhatta Om Prakash meprakashom@gmail.com
b⁎
Gyawali Prakash c
Dangol Rojan Singh a
Joshi Mandeep Dutta d
Neupane Bhoj Raj a
a Department of General Surgery, Gandaki Medical College and Teaching Hospital, Pokhara, Nepal
b Department of Emergency Medicine, Nova Hospital, Dhangadhi, Nepal
c Department of Medicine, Sukraraj Tropical & Infectious Disease Hospital, Kathmandu, Nepal
d Department of Dermatology and Venereology, Manipal College of Medical Sciences, Pokhara, Nepal
⁎ Corresponding author. meprakashom@gmail.com
12 9 2024
10 2024
12 9 2024
123 1102845 8 2024
5 9 2024
9 9 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Ileal perforation is a rare but serious condition that can arise from accidental ingestion of foreign objects. This report discusses an unusual case of ileal perforation peritonitis caused by ingestion of a chicken bone.

Case presentation

A 60-year-old male presented with acute generalized abdominal pain, fever, nausea, and vomiting for three days. A physical examination revealed signs of peritonitis. Imaging results were unremarkable. Emergency laparotomy revealed perforation in the ileum caused by the chicken bone. The perforated segment was resected, and primary anastomosis was performed.

Clinical discussion

Ingestion of foreign bodies, although common, rarely leads to gastrointestinal perforations. Among these foreign bodies, chicken bones are rarely reported, making the diagnosis challenging because of nonspecific symptoms and low clinical suspicion. Prompt surgical intervention is crucial for managing complications such as peritonitis and sepsis.

Conclusion

This case highlights the importance of considering foreign body ingestion in the differential diagnosis of acute abdominal pain, particularly in patients without an obvious cause of peritonitis. Early detection and timely surgical intervention are essential to improve patient outcomes.

Highlights

• Ileal perforation caused by the accidental ingestion of chicken bone is an infrequent and challenging diagnosis.

• Preoperative diagnosis was challenging in a 60-year-old male due to nonspecific symptoms and unremarkable imaging results.

• Prompt resection and primary anastomosis led to successful management of ileal perforation and peritonitis.

• This case emphasizes the need to consider foreign body ingestion in the differential diagnosis of acute abdominal pain.

Keywords

Foreign body
Ileum
Peritonitis
Intestinal perforation
Abbreviations

CT computed tomography

ECG electrocardiography

POD postoperative day

GI gastrointestinal
==== Body
pmc1 Introduction

Ileal perforation peritonitis is a critical and potentially life-threatening condition that necessitates prompt diagnosis and surgical intervention. Although the etiology of gastrointestinal perforation can be diverse, including infectious, inflammatory, and traumatic causes, perforation due to the accidental ingestion of a foreign body is relatively rare [1,2]. Most foreign bodies pass through the gastrointestinal tract without causing serious complications, and less than 1 % can lead to perforation. Large, sharp, or pointed objects are more likely to cause bowel perforations [3]. Foreign bodies, such as dentures, toothpicks, and chicken or fish bones, have been reported to cause gastrointestinal perforation. Perforation caused by ingestion of chicken bones is infrequent and poses a diagnostic challenge because of its uncommon occurrence and nonspecific presentation [3,4].

A 60-year-old male, presented with non-specific abdominal symptoms, highlighting the importance of considering foreign body ingestion in the differential diagnosis of acute abdominal pain, particularly in the absence of a significant medical history. This case underscores the need for high clinical suspicion and thorough diagnostic evaluation to identify and manage the rare causes of gastrointestinal perforation. The case has been reported as per the SCARE checklist [5].

2 Case presentation

A 60-year-old male, non-smoker and non-alcoholic, presented to the emergency room with generalized abdominal pain for three days and fever for one day. Pain was associated with nausea and one episode of non-bilious, non-bloody vomiting. The patient reported a progressive fever of 101.5 °F, which was controlled with over-the-counter antipyretics. The patient had no relevant medical or surgical history.

On examination, his pulse rate was 110 beats per minute, respiratory rate 22 breaths per minute, SpO2 94 % on room air, and blood pressure was 100/70 mmHg. General examination revealed dehydration.

Abdominal examination revealed distension, generalized tenderness, rebound tenderness, guarding, and rigidity. Percussion revealed a tympanic note, and auscultation indicated the absence of bowel sounds. The systemic examination results were unremarkable. Rectal examination revealed an intact anal tone, no masses, an empty rectum without ballooning, a non-tender and palpable prostate, and no blood on the gloves.

Laboratory investigations revealed a total white blood cell count of 6100/mm3 with 84 % neutrophils, hemoglobin level of 16.4 g/dL, platelet count of 145,000/mm3, serum creatinine of 1.0 mg/dL, and serum potassium of 3.3 mmol/L. Electrocardiography (ECG) showed a normal sinus rhythm. Chest and abdominal radiography, both erect and supine, did not reveal any foreign body or evidence of pneumoperitoneum (Fig. 1).Fig. 1 Routine abdominal radiography, both erect and supine, did not reveal the foreign body or any evidence of pneumoperitoneum.

Fig. 1

A provisional diagnosis of appendicular perforation with peritonitis was made and the patient underwent emergency exploratory laparotomy. Intraoperatively, a 5 × 5 mm perforation was found on the antimesenteric border of the ileum, approximately 150 cm proximal to the ileocecal junction. (Figs. 2 and 3) A 4 cm bony spike was located in the lumen with moderate bilious peritoneal collection. (Fig. 4) Wedge resection of the perforated margin was performed, followed by repair of the resected margin. The resected tissue was sent for histopathological examination, which revealed active inflammation and serositis around the zone of perforation. Postoperatively, the patient admitted to consuming chicken meat at a feast three days before presentation.Figs. 2 and 3 Intraoperatively, a 5 × 5 mm perforation was found on the antimesenteric border of the ileum, approximately 150 cm proximal to the ileocecal junction.

Figs. 2 and 3

Fig. 4 Chicken bone extracted from the ileum, identified as the cause of the perforation.

Fig. 4

The postoperative course was uneventful. Oral intake was resumed on the second postoperative day (POD), the drain was removed on the fifth POD, and the patient was discharged on the eighth POD. The patient had a healthy wound site with good healing of the scar tissue and no symptoms during the one-month follow-up.

3 Discussion

Accidentally ingested foreign bodies typically pass through the gastrointestinal (GI) tract without any consequences [6]. However, foreign bodies such as dentures, toothpicks, and chicken or fish bones have been reported to cause gastrointestinal perforation. Despite this, only approximately 1 % perforate the GI tract, which may extend from mouth to the anus. A definitive preoperative history of foreign body ingestion may be uncertain [1].

Small bowel perforations by foreign bodies are rarely diagnosed preoperatively because clinical symptoms are usually non-specific and mimic other surgical conditions, such as appendicitis and cecal diverticulitis [7]. Clinical symptoms vary from abdominal pain with or without fever.

to focal or diffuse peritonitis or intra-abdominal abscess [8]. The risk of perforation is related to the length and the sharpness of the object [9]. Overeating and rapid eating may contribute to the ingestion of chicken bones. It is more common in the elderly who wear dentures, in patients with psychiatric comorbidities, children and in chronic alcoholics [10].

Most perforations occur in the narrow and angulated parts of the GI tract. The distal ileum, cecum, and left colon are the most common abdominal sites of perforation, although an increased incidence of perforation has been reported in association with Meckel's diverticulum and the appendix, which often mimic diverticular disease [12].

Differentials for the condition include typhoid ileal perforation, perforated gastric ulcer, perforated duodenal ulcer, and ruptured appendix which are common causes of intestinal perforation peritonitis [11].

The detection of ingested bony foreign bodies by plain radiography depends on the calcium content of the object and has poor diagnostic value for chicken bones. In one study, initial plain radiography interpretations demonstrated a sensitivity of 24.0 %, whereas initial CT interpretations demonstrated a sensitivity of 75 % for detecting fish and chicken bone impactions [13]. A CT scan with contrast is the preferred investigation, as it can help delineate the exact location of the foreign object and assist in surgical planning when readily available and not delaying surgery. However, in resource-limited settings, where CT scans may not be readily available, clinical decisions should rely on physical findings and the patient's overall condition. Prompt surgical intervention is essential to prevent further contamination, reduce the risk of septicemia, and ensure the best possible outcome for patients. In cases of bowel perforation, pneumoperitoneum, identified as gas under the diaphragm on erect chest radiography, can be observed. However, not all bowel perforations present with signs of pneumoperitoneum on chest radiography [11,13]. CT findings might not always provide sufficient information for a definitive preoperative diagnosis of bowel perforation due to a foreign body [14].

Management of intestinal perforation due to chicken bone involves stabilization and surgical intervention to limit ongoing abdominal contamination and to manage the perforated site. Initial treatment includes fluid resuscitation, intravenous broad-spectrum antibiotics, bowel rest, analgesia, and frequent abdominal examinations [11,15].

Surgical options depend on the perforation site and clinical presentation and involve resection or repair of the perforated site with or without drainage and diversion. Even if imaging does not yield a diagnosis, the patient is operated on, and a foreign body may be found intraoperatively. For small intestinal perforations, repair typically involves closing the perforation in one or two layers. However, if the injury involves significant bowel damage (e.g., more than half the circumference) or if the patient is in shock or is hemodynamically unstable, small bowel resection with primary anastomosis may be necessary [2,15]. Laparoscopic surgery, which minimizes tissue damage compared with traditional open procedures, is often chosen because of its less invasive nature [4,7]. Postoperative care includes continued antibiotics, monitoring for complications, and supportive measures, such as pain management and nutritional support [15].

Septicemia is a significant complication of perforated peritonitis caused by a foreign body and is a major cause of mortality. Early surgical intervention is crucial to prevent further contamination and reduce the likelihood of septicemia [16].

4 Conclusions

This case highlights the importance of considering accidental ingestion of foreign bodies such as chicken bones in the differential diagnosis of acute abdominal pain and peritonitis, even in patients without a significant history. Timely identification and surgical intervention were crucial in managing the ileal perforation peritonitis in this patient. Clinicians should maintain a high index of suspicion for foreign body ingestion, particularly when the patient's history and presentation are atypical. As demonstrated in this case, early diagnosis and appropriate surgical management can lead to favorable outcomes.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Provenance and peer review

Not commissioned, externally peer reviewed.

Ethics approval

Ethical Approval for a case report is exempt at the authors' institution (Gandaki Medical College and Teaching Hospital). It is only necessary to obtain the patient's consent.

Funding

None.

Author contribution

Bijay Panday (BP), Rojan Singh Dangol (RD), Bhoj Raj Neupane (BN) = Study concept, Data collection, and management of the patient.

Prakash Gyawali (PG), Om Prakash Bhatta (OB), Mandeep Dutta Joshi (MJ), = Writing - original draft preparation and editing

BN = Senior author and Manuscript reviewer.

All authors critically reviewed, revised, and contributed to the final article. All authors read and approved the final manuscript

Guarantor

Bijay Panday.

Research registration number

Not applicable.

Conflict of interest statement

All authors certify that they have no competing interests to declare that are relevant to the content of this article.

Data availability statement

All the required information is in manuscript itself.

Acknowledgements

None.
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