Lollipop stick en-route cecum: Mimic of appendicitis

CASE REPORT

A 5-year-old female child was brought to the emergency by the parents for the right iliac fossa pain since 2 days. On examination, the vitals were stable. The patient was given initial medical treatment for pain. Initial biochemical investigations revealed normal blood counts, liver, and kidney function tests. She was referred for abdominal ultrasound which showed inflammatory changes with minimal ascites in the right iliac fossa with probe tenderness; however, appendix was not seen separately. Contrast-enhanced computed tomography (CECT) was done for the patient to rule out acute appendicitis. CECT, however, showed presence of foreign body with perforation in posterior wall of cecum [Figures 1 a and b]. Appendix and terminal ileum were normal. The patient was planned for emergency surgery, and intraoperatively, a plastic stick was seen within the cecum with impending perforation of the posterior wall of cecum [Figure 1c]. On taking careful history, parents recalled patient eating lollipop a few days back and likely had ingested the stick. It was removed by the operating surgeon and local repair of the cecum wall was done with appendectomy. The patient had uneventful post-operative stay and was subsequently discharged on 4^th post-operative day.

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Figure 1:

Sagittal and axial reformatted images of contrast-enhanced computed tomography abdomen shows presence of linear hollow hypodense structure in cecum and ascending colon with its inferior tip abutting the posterior wall of cecum (red arrow in a and b). A small collection was seen adjacent to it in retroperitoneum with few air foci yellow arrow in (b). intraoperative image shows plastic stick (red arrow in c).

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DISCUSSION

Foreign body ingestion is most commonly seen in children from the age of 6 months to 6 years and in 80–90% of cases, the ingested foreign body passes through the gastrointestinal tract without causing any luminal damage.^[1] In approximately 1% of cases, they can lodge within the bowel and get complicated by causing erosions and perforation of the bowel wall.^[2] Most commonly ingested foreign bodies are coins and batteries.^[3] Lollipop stick causing perforation, as seen in our case, in cecum is not yet reported in literature. Depending on the type of foreign body and duration of stay in body, patients can either remain completely asymptomatic or have a variety of abdominal symptoms including abdominal pain, nausea, and vomiting which can lead to clinical confusion with other common ailments in children such as mesenteric adenitis and acute appendicitis which are much more common. A careful history is essential in all pediatric cases presenting in this age group.

Most of the perforations occur at the site of physiological angulation or narrowing, ileal loops account for 83% of the perforations.^[2] Cecum is uncommonly affected due to the presence of IC valve which prevents the angulated and large foreign bodies from entering cecum. Due to the risk of perforation with batteries and sharp objects are treated by bowel resection or primary closure of the perforation, ether through open surgery or laparoscopically.^[3,4]

CONCLUSION

Thus, foreign body ingestion can mimic appendicitis and should be considered as a possible differential in children who present with acute abdominal pain.

TEACHING POINTS

1. Acute appendicitis is a common cause of the right iliac fossa pain in children. Foreign body ingestion is an uncommon cause but should be kept in mind in children especially from 6 months to 6 years of age.

2. Pre-operative investigation with CECT abdomen is essential in children suspected of appendicitis and not confirmed on USG to confirm the etiology and rule out the mimics of appendicitis as in our case.

MCQs

1. What is the most commonly cause of the right iliac fossa in children

   1. Acute appendicitis

   2. Mesenteric adenitis

   3. Ileocecal TB

   4. Foreign body ingestion

   Answer Key: a

2. What is the most common site of perforation in foreign body ingestion

   1. Ileal loops

   2. Stomach

   3. Cecum

   4. Rectum

   Answer Key: a

3. What is the most common clinical complaint in foreign body ingestion by children?

   1. Abdominal pain

   2. Fever

   3. Melena

   4. None, it passes spontaneously

   Answer Key: d