An Unusual Cause of Abdominal Pain: Three Lead Pellets within the Appendix Vermiformis

Appendiceal Foreign Bodies in Adults: A Systematic Review of Case Reports

Adults can accidentally swallow foreign bodies (FBs) with food. In rare occasions, these can lodge in the appendix lumen causing inflammation. This is known as foreign body appendicitis. We conducted this study to review different types and management of appendiceal FBs. A comprehensive search on PubMed, MEDLINE, Embase, Cochrane Library and Google Scholar was performed to detect appropriate case reports for this review. Case reports eligible for this review included patients above 18 years of age with all types of FB ingestion causing appendicitis. A total of 64 case reports were deemed to be eligible for inclusion in this systematic review. The patient mean age was 44.3 ± 16.7 years (range, 18-77). Twenty-four foreign bodies were identified in the adult appendix. They were mainly lead shot pellet, fishbone, dental crown or filling, toothpick, and others. Forty-two percent of the included patients presented with classic appendicitis pain, while 17% were asymptomatic. Moreover, the appendix was perforated in 11 patients. Regarding modalities used for diagnosis, computed tomography (CT) scans confirmed the presence of FBs in 59% of cases while X-ray only managed to detect 30%. Almost all of the cases (91%) were treated surgically with appendicectomy and only six were managed conservatively. Overall, lead shot pellets were the most common foreign body found. Fishbone and toothpick accounted for most of the perforated appendix cases. This study concludes that prophylactic appendicectomy is recommended for the management of foreign bodies detected in the appendix, even if the patient is asymptomatic.

Lead ammunition residues in a hunted Australian grassland bird, the stubble quail (Coturnix pectoralis): Implications for human and wildlife health

Scavenging and predatory wildlife can ingest lead (Pb) from lead-based ammunition and become poisoned when feeding on shot game animals. Humans can similarly be exposed to ammunition-derived lead when consuming wild-shot game animals. Studies have assessed the degree of lead contamination in the carcasses of game animals but this scrutiny has not so far extended to Australia. Stubble quail (Coturnix pectoralis) are one of the only native non-waterfowl bird species that can be legally hunted in Australia, where it is commonly hunted with lead shot. The aim of this study was to characterize lead contamination in quail harvested with lead-based ammunition. The frequency, dimensions, and number of lead fragments embedded in carcasses were assessed through use of radiography (X-ray). From these data, the average quantity of lead available to scavenging wildlife was estimated along with potential risks to human consumers. We radiographed 37 stubble quail harvested by hunters using 12-gauge (2.75”) shotguns to fire shells containing 28 g (1 oz) of #9 (2 mm or 0.08” diameter) lead shot in western Victoria, Australia, in Autumn 2021. Radiographs revealed that 81% of carcasses contained embedded pellets and/or fragments with an average of 1.62 embedded pellets detected per bird. By excising and weighing a sample of 30 shotgun pellets (all had a mass of 0.75 grain or 48.6 mg), we calculated an average lead load of 78 mg/100 g of body mass. This was a conservative estimate, because fragments were not considered. This level of lead contamination was comparable to hunted bird species examined using similar methods in Europe. The quantity and characteristics of lead ammunition residues found suggest that predatory and scavenging wildlife and some groups of human consumers will be at risk of negative health impacts.