Gravel gut: small bowel perforation due to a blunt ingested foreign body

Ask Doctor Smartphone! An App to Help Physicians Manage Foreign Body Ingestions in Children

BACKGROUND

Foreign body ingestion (FBI) represents the most common cause of emergent gastrointestinal endoscopy in children. FBI's management can be quite challenging for physicians because of the variability of the clinical presentation, and the decision tree becomes even more intricate because of patient-specific variables that must be considered in the pediatric age range (e.g., age of patients and neuropsychiatric disorders) in addition to the mere characteristics of the foreign body. We present an application for smartphones designed for pediatricians and pediatric surgeons based on the latest guidelines from the official pediatric societies. The app aims to help physicians manage FBI quickly and properly in children.

MATERIALS AND METHODS

The latest pediatric FBI management guidelines were reviewed and summarized. The flow chart we obtained guided the development of a smartphone application. A questionnaire was administered to all pediatric surgeon trainees at our institute to test the feasibility and helpfulness of the application.

RESULTS

An app for smartphones was obtained and shared for free on the Google Play Store and Apple Store. The app guides the physician step by step in the diagnostic process, analyzing all patient- and foreign body-specific characteristics. The app consultation ends with a suggestion of the most proper decision to make in terms of further radiological investigations and the indication and timing of endoscopy. A questionnaire administered to trainees proved the app to be useful and easy to use.

CONCLUSION

We developed an app able to help pediatricians and pediatric surgeons manage FBI in children, providing standardized and updated recommendations in a smart and easily available way.

Female Adolescent Presenting With Abdominal Pain: Accidental Wire Bristle Ingestion Leading to Colonic Perforation

INTRODUCTION

Abdominal pain in female adolescents is a common presentation to both the emergency department and the outpatient pediatric clinic. The broad differential diagnosis for abdominal pain requires a high index of suspicion to make an accurate diagnosis of foreign body ingestion as the etiology. Foreign body ingestion occurs in all age groups, but sequelae of gastrointestinal tract perforation in children are rare. Treatment for perforation requires consultation of the pediatric general surgeon. Clinicians should take care to not overlook subtle imaging findings or dietary/exposure history, even in the context of a patient with known history of abdominal pain.

CASE REPORT/TECHNIQUE DESCRIPTION

We report the accidental ingestion of a wire bristle from a grill cleaning brush by a female adolescent. The patient, previously treated and seen for constipation and irritable bowel syndrome in the outpatient gastroenterology clinic, was referred to the emergency department after identification of a foreign body on abdominal radiography. Emergency department physicians discovered the history of grilling and consumption of grilled food, facilitating diagnosis of a wire bristle as the foreign body. The metallic foreign body had migrated to the colon, where it perforated and lodged into the abdominal wall, causing acute, focal symptoms. Observation in the hospital with pain control and infection management allowed for elective laparoscopy. The surgical team removed the object with minimal morbidity and avoided laparotomy.

DISCUSSION

Reports of unintended ingestion of wire bristles have been increasingly reported in the literature; however, most focus on injury to the upper airway or upper digestive tract and subsequent endoscopic or laryngoscopic removal. Most reports detail injury in adult patients, pediatric case reports with digestive tract injury are uncommon, and foreign body removal after lower digestive tract injury in children from a wire bristle has not been reported. We caution pediatric emergency medicine and ambulatory providers to consider such an ingestion and perforation in the differential diagnosis of acute-onset, focal, and localizable abdominal pain in children.

Paediatric GI emergencies

Paediatric GI emergencies constitute a wide range of gut pathologies ranging from those that are common, easily diagnosed and treated to conditions that are rarer, often more severe and challenging to manage. Among a myriad of ordinary clinical symptoms and signs physicians have to identify the child with a serious, life-threatening pathology and initiate the appropriate diagnostic and therapeutic pathway. The aim of the review is to present and discuss a selection of key paediatric GI emergencies that provide challenges in diagnosis and treatment. These conditions are classified by their presentation or pathogenesis and include inflammatory conditions, those presenting with GI obstruction or haemorrhage and the ingestion of foreign bodies or caustic substances. The most recent advances regarding the management of these entities are discussed along with key areas of clinical practice and future research.

Colonic obstruction after ingested gravel and stone

This case concerns a 10-year-old boy with a history of behavioral abnormality that arrived at our surgical emergency room with acute abdominal discomfort. The boy had acute colitis-like clinical symptoms resulting from ingested and retained foreign bodies in the colon. These foreign bodies (gravel and stones) had accumulated in the entire colon over a period of 1 year. Attempts to dislodge the foreign bodies from the rectum by mechanical means failed; therefore the possibility of surgical intervention was considered in view of the worsening colitis. However, the problem was finally resolved by repeated basketting by colonoscopy, antibiotics and later laxatives. The case is noteworthy because of the extent of the condition, difficulty of the decision-making, and the relative success of watchful conservative measures.

Ileal perforation induced by a wire from a metal scouring pad in an infant

Foreign body ingestion is a common occurrence in the pediatric population. We present the case of a 1-year-old infant boy who presented with abdominal distention and shock. At laparotomy, he was found to have an ileal perforation caused by a wire from an aluminum scouring pad that his parents were not aware he had ingested. To our knowledge, this is the first case report of a scouring pad-related perforation. This report emphasizes the danger of ingesting fragments of a metal scouring pad and the importance of considering foreign body impaction in the workup of pediatric gastrointestinal perforation.

Accidental ingestion of a cocktail stick

Cocktail stick (CS) ingestion injury has rarely been reported in the literature. It is a serious clinical problem with considerable morbidity and mortality, largely due to the fact that the event is unnoticed by the patient. We report a case of CS ingestion that went unrecognised by the patient and caused a perforation in the mid-small bowel. We discuss how injuries from such events can become a diagnostic challenge. The history should be re-evaluated in any undiagnosed abdominal pain which has an unclear aetiology and negative radiology.

Selected topics in the evaluation of pediatric gastrointestinal mucosal biopsies

The practice of pediatric gastrointestinal pathology provides specific challenges to the pathologist. Often the clinical information accompanying a biopsy specimen will read simply, "failure to thrive." Other situations, such as the evaluation of a neonate's rectal suction biopsy for Hirschsprung disease, are notorious for providing diagnostic challenges in high-pressure situations. In this review, we will discuss several commonly encountered situations in pediatric pathology: the evaluation of pediatric esophageal eosinophilia, a child who has swallowed a non food item, caustic substance, or hot liquid, the evaluation of a pediatric colorectal biopsy with focal active colitis, and the evaluation of rectal suction biopsies for Hirschsprung disease. With each topic, we will discuss a general approach to the case, diagnostic tips, and how to avoid commonly encountered pitfalls. Finally, we highlight key references pertinent to these issues that can he used to help convey pathologic findings to pediatric gastroenterologists.

[Ingestion of foreign bodies in children. Recommendations of the French-Speaking Group of Pediatric Hepatology, Gastroenterology and Nutrition]

Ingestion of foreign bodies is a common pediatric problem. The majority of ingested foreign bodies pass spontaneously. Management of foreign body ingestions varies based upon the object ingested, its location, and the patient's age and past history. Esophageal foreign bodies should be urgently removed because of their potential to cause complications. Ingested batteries that lodge in the esophagus, sharp or pointed foreign bodies in the esophageal or gastric tract, and ingestion of multiple magnets all require urgent endoscopic removal. Flexible endoscopy is the therapeutic modality of choice for most patients. The use of devices such as a latex protector hood or an overtube may facilitate safer extraction of sharp objects.