A computed tomography scan can detect foreign bodies, locate perforations, and guide treatment.
The findings that suggest perforation are thickening of the intestinal walls, increased mesenteric fat density, and, less frequently, gas in the peritoneal cavity, often restricted to the point of perforation. Accidental ingestion of a foreign body together with food is a common clinical problem at emergency care facilities. Perforation of the gastrointestinal tract is more common if the foreign body is elongated and sharp, like a fish bone, chicken bone, or toothpick, and occurs mainly in the small intestine, at points of physiological angulation or narrowing 3.
The clinical presentation is varied and often poses a diagnostic challenge. Patients generally do not report the ingestion of a foreign body, which delays the diagnosis and creates confusion with other diagnostic possibilities. The objective of this study was to describe four cases of intestinal perforation by ingested foreign body and associate the tomography findings with those described in the literature. We reviewed four cases of surgically confirmed intestinal perforation by ingested foreign body, all in the small intestine, treated in the emergency room between July and June All patients presented with acute abdomen at the time of diagnosis.
The perforation was by a fish bone in two cases, by a chicken bone in one case, and by a toothpick in one case. At presentation, none of the patients mentioned the possibility of foreign body ingestion. All cases were investigated by the routine protocol for acute abdomen and computed tomography CT of the abdomen. Patient ages ranged from 64 to 83 years mean, In no case was the foreign body detected by routine X-ray Figure 1. In three patients two with perforation by a fish bone and one with perforation by a chicken bone , the foreign body, due to its calcium density, was identified on the CT scan, as were signs of intestinal perforation, including an image of the foreign body passing through the intestinal wall, distention of the intestinal lumen with liquid stasis and thickening of the intestinal wall , increased mesenteric fat density, and free gas in the peritoneal cavity Figure 2.
In the case of intestinal perforation by a toothpick, the initial diagnosis was inflammatory impaction likely caused by intestinal perforation of unknown cause. Because of its low density, the toothpick was not identified in the initial CT scan.
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However, in a retrospective postoperative evaluation, it could be localized Figure 3. Three of the patients used a dental prosthesis. In one of those patients, the foreign object perforated the intestine in an area of narrowing secondary to the presence of a neuroendocrine tumor in the intestinal wall Figure 4. A: The foreign body was not detected on routine X-rays. B: A CT scan of the abdomen showed a sharp foreign body arrow , with the appearance of a fish bone, piercing the intestinal wall in the ileal segment within the pelvic cavity, accompanied by thickening of the intestinal wall and increased density of the adjacent mesenteric fat.
A: A CT scan of the abdomen showing a sharp foreign body arrow in the distal ileal segment, together with thickening of the intestinal wall. B: During the surgical procedure, a chicken bone fragment arrow was found to be piercing the intestinal wall and the affected intestinal segment was resected. A CT scan of the abdomen showing inflammatory impaction in the pelvic cavity.
Surgery confirmed intestinal perforation by a toothpick, which was detected retrospectively as an image with a slightly higher density than the surrounding tissue, piercing the intestinal wall arrow. A CT scan of the abdomen, showing a foreign body piercing the wall of the ileal loop in the pelvic region A , arrow , with thickening of the intestinal wall, increased mesenteric fat density, and free gas in the peritoneal cavity, indicating intestinal perforation. Note also the nodular lesion with soft parts protruding into the intestinal lumen at the point of the foreign body impaction B , arrow.
Surgery revealed a neuroendocrine tumor in the intestinal wall, resulting in narrowing of the lumen, at the point of perforation by a fish bone. All four patients presented thickening of the intestinal walls and increased mesenteric fat density. In three, the foreign body was identified passing through the intestinal wall, and gas in the peritoneal cavity was observed in only one. Fish bone, ingested accidentally, is the most common cause of perforation of the gastrointestinal tract 5 , although its incidence varies depending on the dietary habits of each population.
In general, patients with intestinal perforation by an ingested foreign body present to emergency facilities with acute abdomen, which can include abdominal pain, nausea, vomiting, fever, peritonitis, abscess, fistula, intestinal obstruction, and gastrointestinal bleeding 6. Patients typically do not report the ingestion of a foreign body, which, together with a clinical profile that is often confusing, can complicate and delay the diagnosis.
Those that are most susceptible to foreign body ingestion include the elderly, denture wearers, alcoholics, and psychiatric patients 6. In the present study, three of the four patients were denture wearers. Ingested foreign bodies are rarely detected on routine X-rays, because they usually have small dimensions and low radiopacity 7 , as well as because they are often obscured by intestinal gas.
Barber Pole Sign in CT Angiography, Adult Presentation of Midgut Malrotation: A Case Report
PC is one of the most common diffuse peritoneal diseases. Peritoneal carcinomatosis without distant metastases represents locoregional disease and has the potential for aggressive locoregional treatment. Most CT scan findings are however nonspecific as both neoplastic and non-neoplastic pathologies of the peritoneum present as soft tissue masses, with or without ascites.
The detailed information about morphology, size and location of peritoneal implants can be obtained. Multidetector Computed Tomography MDCT remains the modality of choice for primary staging, especially in patients with poor compliance for diagnostic examinations, providing a great deal of information about a large volume of tissue and permitting assessment of metastatic extraperitoneal disease.
PCI is considered as an important prognostic indicator, also helpful in guiding therapeutic management. It can also be used in clinical practice during operations. Several methods of classification have been used to investigate the extent of carcinomatosis.
It is the most widely validated and precise quantitative prognostic indicator. It was described by Jacquet and Sugarbaker. It assesses the distribution and implant size of the cancer throughout the abdomen and the pelvis quantitatively. The abdomen and pelvis are divided by lines into nine regions. The small bowel is then divided into four regions. The lesion size of the largest implant is scored as lesion size 0 through 3 LS-0 to LS LS-0 means no implants are seen throughout the regions. LS-1 refers to implants that are visible up to 0.
LS-2 identifies nodules greater than 0. LS-3 refers to implants 5 cm or greater in diameter. Extra-abdominal conditions such as breast cancer , lung cancer and malignant melanoma can involve the peritoneal cavity through the haematogenous spread. Many non-neoplastic and neoplastic conditions may mimic PC, such as tuberculosis, splenosis implant, peritoneal lymphomatosis, pseudomyxoma peritonei and primary peritoneal mesothelioma.
Peritoneum is a thin, translucent serosal membrane of mesodermal origin, covers the surface of the peritoneal cavity, mesenteries and intraperitoneal viscera. The visceral peritoneum covers the intraperitoneal organs, omenta and mesenteries. The parietal peritoneum lines the abdominal walls; undersurface of the diaphragm; anterior surface of the retroperitoneal viscera and the pelvis.
Normally a very small volume of sterile fluid is present in the peritoneal cavity. This fluid continuously circulates upwards to the subdiaphragmatic spaces where the subphrenic submesothelial lymphatics provide most of the lymphatic clearance from the peritoneal cavity. The cephalic movement of peritoneal fluid is augmented by the negative intra-abdominal pressure during exhalation and bowel peristaltic motion. Initially, peritoneal fluid accumulates in gravity-dependent spaces, the deep recesses of the pelvis and the lateral paravesical spaces and then ascends cephalad through the paracolic gutters reaches the subdiaphragmatic spaces.
As the left paracolic gutter is shallow and discontinuous with left subdiaphragmatic space at the phrenicocolic ligament, most of the fluid takes path through the right paracolic gutter.
ouslereawa.tk imaging of the peritoneum and mesentry.
Completion of the circulatory pathway takes place caudally by redirection of fluid into the pelvis through the inframesocolic compartment13 Fig. In pathologic conditions the excessive fluid collects in well-defined areas of stasis or arrested flow including the peritoneal recesses of the pelvis pouch of Douglas in women and retrovesical space in men , the right lower quadrant near the termination of the small bowel mesentery at the ileocaecal junction , the superior aspect of the sigmoid mesocolon and the right paracolic gutter.
Peritoneum can be involved by direct invasion, lymphatic paths, intraperitoneal seeding or hematogenous spread. Direct invasion can be contiguous or non-contiguous. Contiguous peritoneal involvement occurs from the involved organ periphery directly. Non-contiguous direct spread directed by peritoneal reflections, ligaments and lymphatic channels.
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It includes distant metastasis from malignant melanoma, carcinoma breast and lung. Peritoneal seeding is predominantly directed by intraperitoneal circulation of peritoneal fluid. Constant circulation of peritoneal fluid allows transcoelomic dissemination of malignant cells. Their deposition and growth occur at particular sites due to relative stasis of ascitic fluid. Peritoneal carcinomatosis is the most common peritoneal neoplastic condition. Here we present pictorial review of key CT imaging findings with few of the PC mimics.