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Cases
Acute Surgical Abdomen
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Background
This 42-year-old man presents to the emergency department after approximately 30 hours of abdominal pain. The patient's pain was initially mild, constant, and periumbilical, lasting nearly 10 hours before resolving. After he ate breakfast, the pain returned to the right lower quadrant and gradually progressed over the next 20 hours.
The patient denies any fever, nausea, vomiting, diarrhea, constipation, bloody stools, weight loss, testicular pain, or anorexia. Physical examination reveals an afebrile, well-appearing man with localized voluntary guarding and rebound tenderness in the right lower quadrant. In addition, he has positive heel tap, Rovsing, and psoas signs. Contrast-enhanced CT of the abdomen and pelvis is performed (see Image A).
What is the diagnosis?
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down for Hint and Answer
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***** HINT *****
The patient denies ingesting a foreign body, but he cannot tolerate having food stuck between his teeth.
***** ANSWER *****
Although the patient's presentation is classic for appendicitis, he lacks some findings on review of systems. He was in no distress and afebrile, without any anorexia or vomiting. Initial CT of the abdomen showed a thickened terminal ileum; a normal-appearing appendix; and perimesenteric fat stranding, which was read as nonspecific inflammation of the bowel most consistent with regional enteritis. However, because his pain worsened over the next several hours, he was taken to the operating room for diagnostic laparoscopy. As shown on the intraoperative image (see Image B), a toothpick was found perforating the cecum. The toothpick was removed, and the patient had an uncomplicated recovery.
Toothpick ingestions are rare, but the literature includes several case reports. Approximately 70% of patients with reported toothpick ingestions present with abdominal pain. However, only about 12% remember ingesting the toothpick. The onset of symptoms varies, with a reported range of less than 1 day to 15 years after ingestion.
Perforation most frequently occurs at the duodenum and sigmoid, but this case shows that perforation may occur anywhere. Imaging studies are useful in only 14% of cases; laparotomy is the most common method for definitive diagnosis. The overall reported mortality rate is as high as 18% (Li, 2002). As a general rule, patients ingesting sharp objects and objects larger than 2 X 5 cm should be watched closely and treated aggressively.
This case reminds physicians that a CT may be bypassed in a patient with a surgical abdomen. Although the patient lacked some classic symptoms of appendicitis, the history and examination findings were consistent with a surgical abdomen. CT may have delayed the appropriate treatment, which was diagnostic laparoscopy.
For more information on foreign body ingestions, see the eMedicine articles Foreign Bodies, Gastrointestinal, Gastrointestinal Foreign Bodies, and Pediatrics, Foreign Body Ingestion.
Reference: Li SF, Ender K. Toothpick injury mimicking renal colic: case report and systematic review. J Emerg Med. 2002 Jul;23(1):35-8.
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Author:
Troy Paul Coon, MD
Staff Physician, Department of Emergency Medicine, Darnall Army Community Hospital, and Michael Miller, MD, Program Director, Assistant Professor, Department of Emergency Medicine, University of Texas A&M Health Sciences Center, Darnall Army Community Hospital
Darnall Army Community Hospital, Fort Hood, Texas
eMedicine Editor:
John Leung, MD
Northwestern University, Northwestern Memorial Hospital
Source
http://emedicine.com
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