eP587 - ‘The Tooth Is out There’: An Uncommon Case of Sigmoid Colon Perforation Due to Molar Implant Accidental Ingestion

Purpose/Background: Foreign body (FB) ingestion, whether voluntary or incidental, is quite common in the emergency department, however, the rate of bowel perforation in unusual. Approximately 80-90% of ingested FB travel through GI tract without the need for intervention, 10-20% are endoscopically extracted and only 1% require surgical intervention due to bowel perforation. The aim of this study is to evaluate the incidence of bowel perforation caused by foreign body ingestion, risk factors, management and prognosis.Methods/Interventions: A 79-year-old female who presents with generalized abdominal pain. Patient refers accidental ingestion of dental implant 3 days prior onset of symptoms. Physical examination revealed abdominal distension and tenderness on palpation.

Control laboratory studies showed: leukocytes 11.9, neutrophils 90.6%, hemoglobin 12.9 g/dL, and platelets 193. An abdominal tomography revealed a foreign body located at sigmoid colon, with metallic density in bowel lumen as well as air bubbles at perihepatic region suggesting bowel perforation. Urgent surgical treatment was resolved due to the presence of acute abdomen. An emergency exploratory laparotomy showed punctate bowel perforation at sigmoid colon with partial exteriorization of molar implant as well as fecal peritonitis. A Hartmann procedure was performed with foreign body removal and no eventualities. The patient had an adequate postoperative evolution and was discharged 2 days later.Results/Outcomes: The finding of foreign bodies (FB) in the intestinal tract is a common clinical problem, being accidental ingestion the most frequent cause. The ingestion of FB is rarely a cause for complications as most of them travel through the intestinal tract without incidences, however, in less than 10% of cases it causes perforation. Bowel perforation due to foreign body occurs majorly at sites of small caliber such as the pylorus, ileocecal valve and rectosigmoid union. Approximately 75-83% of bowel perforations occur at the ileocecal valve, followed by sigmoid colon with 23.8%.

The clinical presentation is diverse and will depend on the anatomic site of the perforation, adjacent organ compromise and time of evolution. Up to 90% of patients with FB ingestion will present asymptomatic and will course unnoticed. The clinical symptoms are varied: abdominal discomfort, abdominal pain, nausea and vomit, abdominal tenderness, bowel obstruction, GI bleeding, etc. Due to the wide variety of symptoms, diagnosis becomes a clinical challenge; the period of evolution is long, more than 2 weeks in 50% of cases. The effectivity of abdominal x rays on ingested FB depends on its size and density; metallic objects, bone or wood may be detected on computer tomography scans, as well as intraluminal gas; CT scans are ideal for location of perforation site.

Surgical management is reserved for cases in which a complication is encountered such as recurrent abdominal pain, bowel obstruction, hemorrhage, signs of perforation or peritonitis. The surgical approach consists on an exploratory laparotomy, examining the bowel viability, with resection of ischemic bowel segment if necessary and reanastomosis if possible.Conclusion/

Discussion: Bowel perforation caused by ingestion of a foreign body is unusual, its preoperative diagnosis represents a challenge and must be immediately treated surgically. Any delay in the surgical management will result in a higher mobility and mortality; the employed surgical technique will depend on the location of the perforation, local conditions and time of evolution."Sigmoid colon perforation

Partial exteriorization of dental implant through sigmoid
Dental implant

Successful removal of dental implant from sigmoid colon
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