Ingested Foreign bodies masquerading as potential tumours
Foreign bodies (FBs) which are ingested usually pass through the gastrointestinal tract spontaneously. Although deliberate or accidental ingestion is not uncommon, early removal may be only indicated if button batteries or other foreign bodies fail to pass below the diaphragm after 24hours1s . Accidental ingestion of dietary FBs (i.e.fish or chicken bones) is common however within a week, 80-90% of these will pass through the gastrointestinal tract uneventfully. Ingestion of FBs can cause complications such as bowel obstruction, gastrointestinal bleeding, perforation and abscess formation but less than 1% of cases account for these complications2,3,4. We report two cases of FB ingestion which resulted in unusual pathology masquerading as tumours.
52 year old lady presented with two week history of epigastric pain and vomiting. A tender mass in the epigastric region was found on examination. Routine laboratory tests were unremarkable. An ultrasound scan revealed a solid and vascular mass related to the inferior aspect of ligamentum teres, it measured 9 x 8.5 x 7.7cm. A computed tomography (CT) scan revealed a mass related to the anterior gastric antrum, it measured 7.5 x 6.4 cm. The CT scan also demonstrated extensive inflammatory stranding in the omentum and localised lymphadenopathy, however there were no findings of gastric outlet obstruction or malignant disease (Fig 1).
Gastroscopy demonstrated extrinsic compression in the pre-pyloric region. Histology of biopsies taken from the site revealed mild to moderate active chronic inflammation. A mass was found in the transverse colon on colonoscopy. Upon discussion in multidisciplinary meeting, a pre-pyloric mass infiltrating colon, fitted with malignancy in the gastric antrum. Patient underwent laparoscopy whereby a mass between the greater curve of the stomach and the colon was evident; inflammation and omental fat necrosis was also visualised. At laparotomy a hard mobile mass involving the stomach and proximal transverse colon was noted and an en-bloc distal gastrectomy and transverse colectomy was performed. Histopathological examination demonstrated a fishbone within the specimen (Fig 2). Benign fistula extending from colon into the gastric wall with prominent inflammation and formation of abscess was confirmed. Along the fistula tract acute and chronic inflammation as identified but no granulomas were identified. Within the fistula a FB of bony origin with calcified external layer was demonstrated (Fig 3). Post-operative recovery was unremarkable and the patient was discharged seven days later.
A 45 year old gentleman presented with vomiting and acute exacerbation of epigastric pain. He had experienced epigastric pain and dyspepsia for 12 months following forceful swallowing of a foreign body. The alleged event happened abroad; he underwent gastroscopy soon after the event which was reported as normal. Tenderness and guarding in the right upper quadrant was exhibited on examination. Haemoglobin concentration was 3.8 g/dl (Hb) and white cell count was 12100/μl. Abdominal radiograph (Fig 3) showed a centrally located irregular, radiopaque object at L1 level.
Gastroscopy revealed ulceration in the antrum which appeared to be malignant, biopsies were taken. Histopathological examination revealed acute and chronic inflammation, with no features of malignancy. A foreign body (Fig 5) which was extracted from the middle of the ulcer was found to be a magnetic material known as barium iron oxide (Ba3Fe32O51). This is commonly used in fridge magnets or doorstops. A subsequent abdominal computed tomography (Fig 4) still revealed a metal density in the stomach and a large perforating antral ulcer.
The patient underwent a subtotal gastrectomy. Histological examination of the specimen revealed extensive necrosis with chronic and acute inflammation extending from ulcerated mucosa through to muscularis propria; transmural perforation and fibrosis was also present. However there were no features of malignancy and H.pylori was not identified. Post-operative recovery was uneventful; the patient was commenced on oral intake and discharged few days later. On follow up he continued to do well with no complications.
Majority of ingested FBs pass through the gastrointestinal tract spontaneously without any complications. Literature reports of more than 300 cases of bowel perforation secondary to FBs have been identified5. Sites commonly affected are at areas of narrowing and angulation such as the ileocaecal and rectosigmoid junctions . Time of perforation depends on the anatomical site; early presentation and acute perforation tends to be in the small bowel, but later presentation and chronic perforation with formation of abscess tends to occur mainly in the stomach, caecum and sigmoid colon . Ingestion of magnets have been reported to cause intestinal fistula and bowel obstruction . Larger series of cases have shown magnets to be accountable for causing pressure necrosis leading to perforation and or fistulation and bowel obstruction in some patients Ingestion of fish bones are not known to cause gastro-colic fistula; the above case is the first reported case. Gastro-colic fistulae are usually caused by colonic or gastric cancer and benign peptic ulcer disease. Ingestion of foreign bodies may cause complications such as bowel obstruction, gastrointestinal bleeding, perforation, abscess formation, gastrocolic fistulas and granulomas. All of these complications may masquerade as potential tumours as was the case in the above reported cases. FBs may be obscured by fluid and structured tissue masses which can also contribute to the misinterpretation4.
FBs though rarely causing major complications, may occasionally cause misinterpretation of investigations leading to extensive operations.
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