Case report

A 22-year-old man presented to the emergency department complaining of a 6-day history of abdominal pain, localised predominantly in the suprapubic than right iliac fossa. His appetite and bowel habit were unchanged. Past medical history was unremarkable. On examination, he was apyrexial, with guarding and tenderness mainly in the suprapubic and right iliac fossa. Blood tests revealed a white cell count of 11.5 x 10 ⁹ /L, C-Reactive Protein of 21.2mg/L and normal urine analysis. A provisional diagnosis of atypical appendicitis was made and laparoscopic appendicectomy was planned.

At operation, greater omentum was noted to be adherent to the terminal ileum and the appendix appeared inflamed. The omentum was mobilised to enable ease of access for the laparoscopic instruments to the appendix. Following this, the tip of a wooden cocktail stick was visualised protruding from the antimesenteric border of the terminal ileum (Fig.1) about 10 cms from the ileocaecal junction.

Figure 1

Figure 1: Cocktail stick protruding from antimesenteric border of ileum

The entire stick was removed intact and the 3mm perforation closed laparoscopically with interrupted absorbable sutures. Appendicectomy was subsequently performed and histology showed no evidence of active inflammation of the appendix (Fig.2).

Figure 2

Figure 2: shows the wall of the appendix. There is reactive hyperplasia of its submucosal lymphoid follicles but no evidence of active inflammation

There was evidence of an active serosal inflammatory process (Fig.3) suggesting extra- appendiceal inflammation.

Figure 3

Figure 3: a) fibrin deposition with accompanying inflammation on the appendiceal serosa. b) mesothelial hyperplasia and granulation tissue reaction.

On questioning the patient, he had no recollection of swallowing the cocktail stick. He was discharged home after two days without any complications.

Discussion

The majority of ingested cocktail sticks pass through the gastrointestinal tract without consequence; however, intestinal perforation, fistulation and death have all been reported. ₂₃ Gastrointestinal perforation secondary to cocktail stick ingestion is rare and most commonly occurs at the duodenum, followed by the sigmoid colon. Most of the injuries are due to broken cocktail sticks. In a systematic review by Li et al., definitive diagnosis was reportedly made at laparotomy (53%), endoscopy (19%), post-mortem (12%) or on radiological imaging (14%). ₄ Plain radiography is normally unable to demonstrate the stick, which is normally made of wood or plastic, making diagnosis difficult. In addition, only 12% of patients ever remember swallowing the cocktail stick. The symptoms and signs may mimic other acute abdominal pathology and onset may range from <1 day to 15 years.

The laparoscopic management of small and large bowel perforation related to cocktail stick ingestion is rarely reported. Indeed, there is only one other reported case of ileal perforation related to cocktail stick ingestion repaired laparoscopically. ₅ More commonly, these injuries have been detected at laparotomy and this case highlights the potential use of a minimally invasive approach in this situation without complications. Indeed, in atypical presentations of appendicitis, laparoscopy probably provides a more accurate and thorough assessment of the peritoneal cavity to exclude other causes than the conventional open approach. In this case it remains uncertain whether intestinal injury would have been detected at open operation, since it was unlikely to have interfered with appendicectomy and also macroscopically the appendix appeared inflamed.

In the atypical presentation of abdominal pain, this case illustrates that whilst it is undoubtedly helpful to ask leading questions regarding foreign body ingestion, only a small number of patients recollect the event. Also, in view of the potentially serious complications relating to cocktail stick ingestion, they should carry a warning sign.

Correspondence to

Dr Sivakumar Gopalswamy MBBS, MS, DNB, MRCS. 101-D, KYNANCE HOUSE, ROYAL CORNWALL HOSPITAL & PENINSULA MEDICAL SCHOOL, TRURO UNTED KINGDOM TR1 3LZ E-mail: vgshiva@yahoo.com Mobile: 0044-7738677480 Work: 0044-1872 250000-bleep 2105