ABSTRACT
Introduction: Foreign body (FB) ingestion is a common occurrence, with most expected to pass spontaneously once in the lower gastrointestinal (GI) tract, distal to the ileocecal (IC) valve with no currently established management guidelines. Case Description/Methods: A 76-year-old female had 2 days of intermittent left lower quadrant pain and diarrhea. Abdominal exam was without peritoneal signs. She tested positive for COVID 19 with mild upper respiratory symptoms. Patient had history of bowel obstruction requiring surgery more than 20 years ago. CT abdomen showed a 5 cm linear, hyperattenuating FB in the sigmoid colon, without inflammation or perforation (Figure 1A). She denied swallowing a FB. Conservative management with Miralax, docusate, and clear liquid diet for 3 days failed as her abdominal pain persisted and daily X-rays were unchanged despite daily bowel movements. Repeat CT showed unchanged location of the FB, which was now embedded in the sigmoid wall, with local inflammation. Sigmoidoscopy revealed a 4 cm linear bone fragment embedded in the sigmoid colon wall, which was retrieved with rat-tooth forceps (Figure 1B). Her pain resolved within 24 hours. Discussion: Boney fragments are common sources of accidental FB ingestion. Iatrogenic sources are also reported, such as needles lost during dental procedures. Such sharp objects have a greater association with complications, including perforation and bleeding which can be life threatening. Size, shape, or number of objects are not always predictive of ability to transit the GI tract. Approximately 80% of objects pass spontaneously and are almost always expected to pass once they have advanced beyond the IC valve. Objects found within the upper GI tract are of common concern, with existing management guidelines, however there are currently no established management guidelines for ingested FBs within the lower GI tract. In our case, the object was expected to pass without endoscopic intervention, but failed to progress over 72 hours, and was instead embedded within the sigmoid colon wall. Although signs of complications, such as perforation typically present themselves clinically, there are sometimes cases of clinically “silent perforation” with sharp objects in the GI tract, which could be missed with conservative management. This case highlights the need for clearly established guidelines for the management of ingested FBs within the lower GI tract, with interval imaging and defined threshold for endoscopic intervention of particular importance.