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