Intestinal perforation secondary to foreign body .pptx

This is a case of multiple Intestinal perforations secondary to the ingestion of multiple magnets, the last adheres to each other at different levels of the intestine causing wall ischemia and perforation.

1. Dr . Majd AlHaddadin , MBChB,MS,MRCS,AFACS Consultant General & Laparoscopic Surgeon Al Hammadi Hospital – Riyadh – Nuzha - Jordanian Board and Arab Board in General Surgery. - Member of T he Spanish Association of Surgery (AEC). - Member of The Royal College of Surgeons – Ireland (MRCSI). - Associate Fellow of the American College of Surgeon (AFACS).

2. Non-Traumatic Multiple I ntestinal P erforations Case P resentation Dr. Majd AlHaddadin, MBChB, MS, MRCS, FACS Consultant General & Laparoscopic Surgeon Al Hammadi Hospital – Nuzha – Riyadh- Saudi Arabia

3. Introduction Accidental ingestion of a foreign body together with food is a common clinical problem at emergency care facilities. Voluntary ingestion of a foreign body is not common. Although most ingested foreign bodies pass through the gastrointestinal tract without consequences within one week . I n up to 1% of cases perforation occurs at some point in the gastrointestinal tract.

4. Introduction Perforation of the gastrointestinal tract is more common if the foreign body is elongated and sharp, like a fish bone, chicken bone, or toothpick, and occurs mainly in the small intestine, at points of physiological angulation or narrowing. The clinical presentation is varied and often poses a diagnostic challenge. Patients generally do not report the ingestion of a foreign body, which delays the diagnosis and creates confusion with other diagnostic possibilities.

5. Case Presentation A 15 year — old, with no past medical, surgical or physiological history ER visit on 18/ oct /2021: - lower abdominal pain of 4 days duration Low grade fever No improvement on analgesia Physical examination : Lower abdominal pain and tenderness, signs of localized peritonitis.

6. Relevant Investigations: Labs: Wbc 10.9 X 10^9/L Neutrophils: 90.8 C-reactive protein 20 mg/L Abdomen US RIF: tender on probing, appendix seen at the right iliac fossa with outer wall to wall diameter about 8.9 mm with small free fluid collection & echogenic fat, there is tubular echogenic structure seen at the right iliac fossa with posterior acoustic shadowing, could be appendicolith . ???

7. Abdomen X Ray Air - Fluid levels Foreign Body ??

8. Decision: Ct scan abdomen : No Urgent diagnostic laparoscopy. Initial diagnosis: acute appendicitis. Consent for laparotomy and bowel resection obtained . Preoperative anesthesia assessment.

9. Diagnostic laparoscopy findings : Conglomerated bowel loops

10. Jejunum and Ileum perforations Small Bowel perforation

11. Sigmoid perforation, What to do? To do or Not to do diverting colostomy?

12. Procedure and postoperative course Primary repair of the three perforations with extraction of the foreign bodies done, and no colostomy. The patient discharged on Day 4. Good general condition . No complications.

13. Discussion A variety of foreign bodies are ingested unintentionally during rapid eating, particularly by persons with reduced  palate  sensitivity . Young children, elderly and mentally challenged people are usually at a higher risk. Ingested foreign bodies may perforate anywhere along the GI tract  ,but more commonly in the anatomical or physiological narrow or curved areas.    In order to identify site and cause of a GI perforation a CT scan of the abdomen and pelvis before and after  iv administration  of  contrast  should be preferred over a Ct scan with oral contrast. In fact, in the emergent setting, the study should not be delayed trying to administer oral contrast, moreover the use of oral contrast during CT can make more difficult to detect a radiopaque foreign body.  

14. Surgical repair of gastrointestinal perforation depends on many factors: The site of the GI tract perforation (esophagus, stomach, duodenum, colon, rectum… etc ) The size of the perforation and the percentage of the circumference affected by the perforation. Grade of intrabdominal infection, peritonitis, stability, sepsis ... etc Whether the site of perforation has healthy tissues or not.

15. CONCLUSION Intestinal perforation secondary to a foreign body is quite rare and the surgeon needs a high index of suspicion to do a proper diagnosis. CT scan of abdomen and pelvis is useful to make a proper diagnosis, but it can delay the prompt management of a perforation.  S urgical management of intestinal perforation depends on the site , size of the perforation and the grade of intraabdominal contamination, in addition to the healthiness of the tissues.

16. Thank You…