AJR 2001; 176:153-154
© American Roentgen Ray Society
Sigmoid Carcinoma Incidentally Discovered After Perforation Caused by an Ingested Chicken Bone
Eleni Vardaki1,
Vassilios Maniatis1,
Harris Chrisikopoulos2,
Andreas Papadopoulos1,
Arkadios Roussakis2,
Spiros Kavadias1 and
Kiriakos Stringaris1
1
CT Department, "G. Genimatas" General Hospital, Mesogeion 154,
Athens 11527, Greece
2
CT Department, "Hygeia" Hospital, Kifissias Ave. & Erithrou
Stavrou 4, Maroussi, Athens 15123, Greece.
Received April 21, 2000;
accepted after revision August 7, 2000.
Address correspondence to V. Maniatis.
Introduction
Gastrointestinal perforation results in an emergency situation that
requires prompt treatment. There is a broad spectrum of etiologic factors that
cause gastrointestinal perforation, neoplasms and foreign bodies among them.
Ingested foreign bodies are likely to stop at any narrowing or angulation of
the intestinal lumen, and perforations usually occur above the colon. We
report a case of a perforation caused by an ingested foreign body at a site of
a pathologically (because of a previously unknown carcinoma) narrowed lumen in
the sigmoid colon.
Case Report
A 69-year-old man was admitted to our hospital with acute abdominal pain
and clinical signs of peritoneal irritation. Laboratory studies showed a WBC
count of 19.560 mm3 (92% of the total WBC were of the
polymorphonuclear type) and slightly decreased hematocrit (39.4%) and
hemoglobin levels (12.3 g/dL). An unenhanced radiograph of the abdomen
revealed nonspecific findings. After oral administration of meglumine
diatrizoate (Gastrografin; Bracco Diagnostics, Princeton, NJ), the patient
underwent CT of the abdomen that showed the following: free intraabdominal air
at the left anterior perihepatic space; opacity of the perisigmoid fat, where
bubbles of air were also seen; and an intraluminar, linear, radiopaque foreign
body with maximal length of 15 mm (Figs.
1A and
1B). A small amount of ascitic
fluid was present in the Douglas bag. No enlarged lymph nodes were seen. The
diagnosis of sigmoid colon perforation by a foreign body was suggested. During
surgery, an inflammatory polypoid mass was detected at the site of a
perforation, caused by a chicken bone. Retrospective study of the CT scan
revealed a localized bulging of the intestinal wall at this area, probably
representing the neoplastic lesion (Fig.
1B). An ileal loop was attached to the mass, and its mesenteric
border was ruptured. Pathologic study of the resected mass revealed a sigmoid
colon adenocarcinoma. Postoperative recovery was uneventful. The rest of the
radiologic examination revealed no metastases.
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Fig. 1B. —CT scans of abdomen in 69-year-old man who presented with
acute abdomen. Linear radiopaque foreign body (double arrow) is
present in sigmoid colon lumen. Bulging soft-tissue mass can be seen at
sigmoid colon wall (single arrow).
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Discussion
Ingestion of a foreign body is not a rare incident and is reported most
commonly among elderly people who wear dentures, individuals who have a mental
impairment, and those who chronically abuse alcohol
[1]. Most foreign bodies pass
through the gastrointestinal tract uneventfully, but perforations can occur at
any site along the tract, mainly at narrowings and angulations or in anatomic
cul-de-sacs [2]. Radiologic
evaluation of these patients is of great importance; it usually starts with an
unenhanced radiograph of the abdomen, which in most patients shows no specific
findings and does not enable visualization of nonmetallic foreign bodies. CT
examination usually provides the preoperative diagnosis of perforation and
clearly shows the cause because CT can depict foreign bodies of almost any
density.
Perforations due to ingested foreign bodies usually occur higher than the
colon. On the other hand, spontaneous rupture of the large bowel is uncommon,
but it can occur when the bowel wall is friable (e.g., ischemic or ulcerative
colitis, diverticulitis, necrotic tumor)
[3]. In a report with large
series, the frequency of perforation of colorectal neoplasms has been cited as
2.5-8% at initial presentation
[4]. The location of the
primary perforated neoplasm was the sigmoid colon in most patients, with the
remaining colonic segments (the cecum and ascending colon, the transverse
colon, the rectum, and the descending colon) following in frequency in that
order [4]. At initial
presentation, almost half of the patients were toxemic and the rest had a
milder clinical presentation with different clinical manifestations. Less than
one third had advanced disease (metastases, direct extension)
[4].
The clinical presentation of sigmoid colon perforation may be that of an
acute abdomen, but a more insidious presentation is more frequently observed,
with abdominal pain, fever, nausea, and vomiting. The nonspecificity of
clinical presentation makes radiologic evaluation necessary. If the cause of
the perforation is—as it was in our patient—a nonmetallic foreign
body, the unenhanced radiograph will probably not show it. Secondary signs of
hollow viscus perforation seen during conventional radiologic examination
could be helpful but reveal neither the segment of gastrointestinal tract
involved nor the etiologic factor. CT examination provides the preoperative
diagnosis of gastrointestinal perforation and all the valuable information
concerning the exact site, extent, cause, and possible complications of the
perforation.
We report a case that is rare because of the complex pathology, which is
the reason why the presence of a tumor was not clinically suspected and not
radiologically evaluated in the first place. The patient was in an emergency
situation and once the diagnosis of sigmoid colon perforation had been
obtained, he was taken to the operating room immediately. Moreover, it is a
justifiable clinical tendency not to suspect a third pathologic process.
However, the following CT findings may raise the suspicion of a neoplastic
infiltration in cases of foreign-body perforation of the gastrointestinal
tract: localized bulging of the bowel wall at the rim opposite the point of
foreign-body penetration, lymphadenopathy, bowel obstruction, and hepatic
metastases. The advantages of CT examination depend on its ability to image
the full thickness of the bowel wall and the surrounding tissues.
We want to stress the extremely useful role of preoperative CT, because it
can reveal not only the perforation but also the radiopaque foreign body and
signs suggestive of a neoplastic infiltration. CT can also help in the staging
of the disease and, therefore, postoperative therapeutic planning.
To our knowledge, only two similar cases have been previously reported, one
in the English literature (sigmoid colon perforation caused by chicken bone)
[2] and one in the German
literature (sigmoid colon perforation due to foreign body)
[5]. In both cases, there were
no CT findings suggesting a neoplasm, which was found only during surgery.
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Introduction
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