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Foriegn bodies in the abdomen - common, not so common
and the exotic
Poster No.:
C-1458
Congress:
ECR 2014
Type:
Educational Exhibit
Authors:
E. C. nandury , S. Boppana , B. V. Mallula ; Hyderabad/IN,
1
2
2
3 1
3
Hyderabad, AP/IN, Hyderabad, Andhra Pradesh/IN
Keywords:
Foreign bodies, Eating disorders, Localisation, Diagnostic
procedure, Contrast agent-oral, Plain radiographic studies, Digital
radiography, CT, Gastrointestinal tract, Colon, Abdomen
DOI:
10.1594/ecr2014/C-1458
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Learning objectives
1. Identify various foreign bodies on imaging modalities, especially radiographs and CT
scans.
2. Detect complications at imaging
Background
Foreign bodies are rare, at times beguiling, may masquerade infections or neoplasms and
can cause serious complications. Young children, emotionally labile persons, alcoholics,
drug intoxicated, people with poor visual acuity and rapid eaters are predisposed.
Foreign bodies may be ingested (Fig 1), inserted into body cavities or may enter the body
by penetrating injury (Fig 2) or iatrogenically. Foreign body ingestions are commonly seen
in young children and mentally challenged adults. Most ingested foreign bodies traverse
the gastrointestinal tract uneventfully. However sharp objects like needles or open safety
pins may get impacted at normal points of intestinal narrowing such as duodenal loop,
duodenojejunal junction or terminal ileum. Impaction of sharp objects or larger blunt
objects may occur at areas of bowel strictures. The complications may include bowel
perforation, obstruction, peritonitis, abscess formation and fistula.
Radiographically foreign bodies can be opaque (Fig 3) or non-opaque. Radiopaque
materials include glass, most metals, most animal bones, certain types of foods, certain
type fish bones, sand, medications and certain poisons.
Most types of food, most types of medicines, most types of wood, most aluminum objects
and most types of plastics are non-opaque.
In case of suspected metallic/opaque foreign bodies, plain radiographs are the initial
modality of investigation. Serial radiographs may be performed to monitor the passage of
ingested opaque objects through the gastrointestinal tract. Radiographs may also reveal
complications of foreign body ingestion such as intestinal obstruction and perforation. In
children or mentally unstable adults with a history of foreign body ingestion, it is essential
to image from the base of the skull to the rectum for detection and accurate localization.
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CT scans are usually performed for accurate localisation (Fig 4) and to assess
complications like peritonitis (Fig 5), obstruction, abscess formation, fistula formation and
in those situations where plain radiographs are non-contributory.
Care should be taken when performing MRI scans in patients with a history of foreign
body ingestion or foreign body injury as they can cause significant image degradation
but more importantly they can be hazardous (Fig 6).
Images for this section:
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Fig. 1: Swallowed key. Abdominal radiograph in an 8 month old female child reveals a
swallowed key in the midline pelvis overlying the L5-S1 vertebrae.The key passed off
uneventfully
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Fig. 2: Needle in the gastric antrum. Axial contrast enhanced CT section in a 65 year old
female presenting with severe right hypochondriac pain reveals a hyperdense metallic
needle perforating the gastric antrum and extending up to the anterior abdominal wall.
The patient denied history of ingestion/insertion and was treated surgically.
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Fig. 3: Swallowed glass bangle piece. Abdominal radiograph in 21 year old female with
history of accidental ingestion of a bangle piece reveals a small linear radiopaque density
in the mid descending colon, which passed off uneventfully.
Fig. 4: Metallic foreign body in the perirectal region. Axial radiograph of the pelvis and
CT scan in a 65-year-old male reveal a small incidental metallic foreign body in the
right anterior perirectal region abutting the right seminal vesicle. There was no history
of foreign body injury.
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Fig. 5: Retained surgical sponge. 25-year-old female with a past history of cesarean
section presenting with severe pain abdomen. CT topogram reveals a large mottled
density in the right lumbar/iliac fossa regions (red circle). Contrast-enhanced axial CT
sections reveal a large soft tissue density with mottled air lucencies in the right lumbar
region suggestive of a retained surgical sponge(arrow). There is also large amount of
intraperitoneal fluid with pneumoperitoneum and peritoneal enhancement suggestive of
peritonitis.
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Fig. 6: Incidental detection of a metallic foreign body in the small bowel mesentery on
MRCP examination in a 55-year-old male with cholelithiasis. MRCP image reveals a
linear transverse filling defect in the distal CBD extending into the adjacent soft tissues
due to a susceptibility artifact. Coronal T2 HASTE MRI reveals large susceptibility artifact
in the region of the duodenum. A subsequent abdominal radiograph and axial CT sections
reveal a linear metallic foreign body in the small bowel mesentery on the right side. Patient
denies any significant past history of foreign body injury.
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Findings and procedure details
Foreign bodies are relatively uncommon in clinical practice, but can cause serious
difficulty in diagnosis and treatment. They can be ingested, inserted into body cavities
by injury or iatrogenic procedures.
Most ingested foreign bodies traverse the gastrointestinal tract without major problem
(Fig 7, Fig 8 & Fig 9). Foreign bodies can be multiple and finding one should prompt a
thorough search for others.
Most animal bones, glass and metallic foreign bodies are radioopaque with the exception
of aluminum. Most plastic, wood and fish bones are non-opaque.
Foreign body ingestion is common in children (Fig 10) and mentally challenged adults
(Fig 11 & Fig 12). The common objects ingested include coins, watch batteries, needles,
safety pins and razor blades. Most of the ingested foreign bodies pass uneventfully
through the gastrointestinal tract.
Watch batteries are commonly ingested by young children and usually pass without
complications (Fig 13).
However they can cause serious complications when the capsule breaks causing the
alkaline corrosive contents to spill into the intestine leading to perforation, septicaemia
and even death.
Pica is characterized by an appetite for substances largely non-nutritive, such as ice,
clay, chalk, dirt, or sand and is usually seen in children and women (Fig 14). Causes
include habits from a cultural tradition, acquired taste or a neurological mechanism such
as an iron deficiency or chemical imbalance.
Sharp objects may not pass easily and can cause complications such as perforation or
obstruction (Fig 15).
Perforation of the gastrointestinal tract is seen in less than 1% of patients with foreign
body ingestion. The most common sites include the ileocecal region, appendix and
Meckel's diverticulum.
Majority of the fish bone ingestions pass off uneventfully. Fish bone perforation in the
abdomen and pelvis, distal to the esophagus is uncommon and occurs in less than 1
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% of cases. The common sites of perforation include the ileum, ileocecal junction and
rectosigmoid. On CT scan a fish bone is seen as a curvilinear density with surrounding
inflammation or abscess (Fig 16, Fig 17 & Fig 18).
Most wooden foreign bodies, thorns and splinters are nonopaque and can present
significant difficulty in diagnosis and can be surprises at surgery or imaging performed
for other reasons (Fig 19, Fig 20 & Fig 21).
Foreign body injuries may result from accidents or iatrogenic causes (Fig 22).
Predisposed patients include children, mentally challenged adults, persons with deviant
sexual practices, military personnel, persons undergoing surgery and instrumentation,
drugs and alcohol abuse and victims of physical abuse (Fig 23 & Fig 24). The detection
of nonopaque foreign bodies may be difficult and requires cross sectional modalities like
ultrasound or CT scan for detection.
Various dislodged tubes, biliary prosthesis and stents (Fig 25) may be detected in the
gastrointestinal tract and can remain asymptomatic or cause significant problems like
bowel obstruction or perforation.
Bullet injuries are uncommon in the Indian subcontinent as compared to the western
hemisphere. Shot gun pellets can be composed of lead or more commonly steel and
can often be differentiated at radiography. Lead pellets tend to deform and fragment on
contact with the body; where as steel pellets tend to remain round (Fig 26).
Retained surgical materials are rare but include surgical sponges, needles and forceps.
Significant difficulty can be encountered clinically and radiographically in detection of
retained surgical sponges (Fig 27).
At CT a retained surgical sponge typically appears as a mass of soft tissue attenuation
and may show mottled gas lucencies. A hyperdense linear marker when seen provides
a clue to the origin of the mass (Fig 28).
Images for this section:
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Fig. 7: Swallowed nails in a 27 year old male prisoner with suicidal intent. Admission
radiograph reveals 2 metallic nails in the midabdomen (stomach). Radiograph done 3
days later reveals a single nail in the ascending colon. Subsequent radiograph done a
day later reveals a progression of the nail into the mid transverse colon. CT sections
show the presence of nails in the duodenum. Both the nails passed out uneventfully.
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Fig. 8: Swallowed ear stud. Radiographs of the abdomen (erect and lateral) in a 2 year
old female child reveal a radiopaque foreign body in the pelvis on the right side, likely
in the terminal ileum.
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Fig. 9: Swallowed denture in the stomach. Axial CT section of the upper abdomen reveals
a small denture in the stomach showing streak artefacts
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Fig. 10: Swallowed coin in the stomach. Erect radiograph of the chest and upper
abdomen in a 6-year-old male child reveals a coin in the stomach
Fig. 11: Multiple foreign bodies in the abdomen in a 36 year-old male chronic
schizophrenic. Abdomen radiograph reveals a nail, tubular opacities in the stomach, large
nail in the region of the duodenum, a needle in the region in the right iliac fossa and a
nail in the mid abdomen to the left of midline. Axial CT sections reveal similar findings.
Surgical exploration was performed and all the foreign bodies were extracted. Multiple
adhesions, 2 ileo-ileal fistulae & 1 jejuno-colic fistula were seen which were treated by
multiple resections, anastomosis and transverse colostomy.
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Fig. 12: Multiple foreign bodies in the abdomen in a 36 year-old male chronic
schizophrenic (same patient as figure 11). Specimen photograph shows multiple pens,
nails and screws which were removed surgically.
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Fig. 13: Ingested watch battery. Admission abdominal radiograph in a 14-year-old
male reveals a swallowed watch battery in the stomach. Radiographs obtained a day
later revealed the battery located in the region of the rectum. The battery passed out
uneventfully.
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Fig. 14: Pica. Supine abdominal radiograph reveals extensive small nodular opacities
filling the entire colon due to chronic eating of sand/gravel in a 10 year old child with
chronic anaemia.
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Fig. 15: Multiple ingested sewing needles. Abdominal radiograph in a 15 year old female
tailor obtained in March with attempted suicide reveals multiple sewing needles in the
upper abdomen. All these needles passed out uneventfully without causing perforation.
Another suicidal attempt 6 months later (September) reveals three needles in the region
of the stomach on an abdominal radiograph. These also passed out uneventfully.
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Fig. 16: Fish bone causing perforation of the terminal ileum with abscess formation. Axial
non-contrast and contrast-enhanced CT sections in a 40-year-old male patient reveals a
large abscess in the retrocecal region with a linear hyperdense fish bone.
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Fig. 17: Fish bone causing gastric antral perforation in a 50 year old female who
presented with severe epigastric pain of 4 days duration. Ultrasound images of the upper
abdomen reveal gastric antral wall thickening, a linear hyperechoic lesion projecting
from the stomach into the perigastric region with small perigastric fluid collection. Axial
contrast-enhanced CT images reveal similar findings (Fig 18)
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Fig. 18: Fish bone causing gastric antral perforation in a 50 year old female who
presented with severe epigastric pain of 4 days duration. Axial contrast-enhanced CT
images reveal gastric antral wall thickening, a linear hyperdense lesion projecting from
the stomach into the perigastric region with small perigastric fluid collection. Figure 17
reveals ultrasound images of the same patient.
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Fig. 19: Long wooden stick in the jejunum in a 21-year-old male who presented with
chronic pain in the left lower abdomen and alternating constipation/diarrhoea of 4 months
duration. There is also a past history of surgery for Hirschsprung's disease at one year
of age. Axial CT sections reveal mild dilatation of small bowel loops with no evidence of
any foreign body.
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Fig. 20: Long wooden stick in the jejunum in a 21-year-old male who presented with
chronic pain in the left lower abdomen and alternating constipation/diarrhoea of 4 months
duration. There is also a past history of surgery for Hirschsprung's disease at one year
of age. Axial CT sections of the pelvis reveal mild dilatation of small bowel loops with
no evidence of any foreign body. Contrast opacification of the left colon is seen with
unopacified right colon suggesting a jejunocolic fistula. Surgery revealed a jejunal colic
fistula and a long wooden stick in the proximal jejunum (shown in Fig 21)
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Fig. 21: Long wooden stick in the jejunum in a 21-year-old male who presented with
chronic pain in the left lower abdomen and alternating constipation/diarrhoea of 4 months
duration. There is also a past history of surgery for Hirschsprung's disease at one year
of age. Axial CT sections of the pelvis reveal mild dilatation of small bowel loops with
no evidence of any foreign body. Contrast opacification of the left colon is seen with
unopacified right colon suggesting a jejunocolic fistula. Surgery revealed a long wooden
stick in the proximal jejunum and a jejuno- colic fistula. The origin of the foreign body
is not known.
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Fig. 22: Migrated nail from the shoulder prosthesis into the abdominal wall. Radiograph
of the right shoulder and abdomen reveals compression plate and screws fixing a fracture
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of the proximal humerus and migrated nail from the shoulder into the right lateral upper
abdominal wall (arrow).
Fig. 23: Needle in the anterior abdominal parietes with abscess formation in a 63-yearold woman who gives a vague history of a missing needle many years ago. Radiograph of
the pelvis reveals a linear metallic opacity in the pelvis on the right side. Axial CT sections
(Fig 24) reveal a needle in the anterior parietes with perforation of the peritoneum a/w
a parietal abscess.
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Fig. 24: Needle in the anterior abdominal parietes with abscess formation in a 63-yearold woman who gives a vague history of a missing needle many years ago. Radiograph
of the pelvis (Fig 23) reveals a linear metallic opacity in the right iliac region. Axial CT
sections reveal a needle in the anterior parietes with perforation of the peritoneum a/w
a parietal abscess.
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Fig. 25: Migrated esophageal stent. Barium meal study reveals malignant stricture in the
distal oesophagus/GE junction and a migrated esophageal stent lying in the body/antrum
of the stomach.
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Fig. 26: Multiple shotgun pellets in the back and abdomen with discharging sinuses in a
35-year-old male. Sinogram of the lumbar spine reveals multiple small metallic densities
in the abdomen and lumbar spine region, L3-4 discitis and osteomyelitis and a long sinus
tract extending from the back on the right side to the L3-4 disc.
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Fig. 27: Retained surgical sponge after vaginal hysterectomy in a 49-year-old female
presenting with pain abdomen. Transabdominal ultrasound images reveal a hypoechoic
lesion posterior to the bladder showing dense posterior acoustic shadowing. Axial CT
scan image reveals a soft tissue density posterior to the urinary bladder which was proved
to be a surgical sponge at surgery.
Fig. 28: Retained surgical sponge after hysterectomy and marsupialisation of a left
ovarian cyst in a 47-year-old female who presented with chronic pain abdomen. Axial CT
image reveals a large mottled gas lucency beneath the anterior abdominal wall showing
a curvilinear central hyperdensity characteristic of a retained surgical sponge.
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Conclusion
Foreign bodies can be opaque or nonopaque, can be ingested, inserted into body cavities
and can be a result of penetrating trauma or iatrogenic injury. Radiographic and cross
sectional imaging studies can aid in accurate localization, detection of complications and
aid in screening before an MRI examination. Imaging should extend from the base of the
skull to the rectum in case of an ingested foreign body.
Personal information
1.Dr E C Nandury Professor and Head, Department of Radiology, Kamineni Academy of
Medical Sciences and Research Centre, Hyderabad, India
[email protected]
2. Dr S Boppana, Dr B V Mallula Department of Radiology, Kamineni Academy of Medical
Sciences and Research Centre, Hyderabad, India
References
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3. Girish Bathla, Lynette LS Teo and Sunita Dhanda. Pictorial essay: Complications of a
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4. Stawicki SP, Evans DC, Cipolla J, Seamon MJ, Lukaszczyk JJ, Prosciak MP, Torigian
DA, Doraiswamy VA, Yazzie NP, Gunter Jr OL and Steinberg SM. Retained surgical
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