An Impacted Clamshell in the Duodenum Mistaken for a Gall Stone

Article information

Korean J Intern Med. 2007;22(4):292-295
Publication date (electronic) : 2007 December 20
doi : https://doi.org/10.3904/kjim.2007.22.4.292
1Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea.
2Department of Radiology, Kyungpook National University School of Medicine, Daegu, Korea.
Correspondence to: Seong Woo Jeon, M.D., Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University School of Medicine, Samduk-2-ga, Jung-gu, Daegu 700-721, Korea. Tel: 82-53-420-5515, Fax: 82-53-426-8773, sw-jeon@hanmail.net
Received 2007 March 06; Accepted 2007 July 31.

Abstract

Although most ingested foreign bodies pass through the gastrointestinal tract spontaneously, those that are sharp, pointed, or large require removal to avoid serious complications. Here we report an interesting case of a 60-year-old man who swallowed a clamshell that passed through the pylorus and was caught in the duodenum. Radiologic findings made it look like a biliary stone. Endoscopic retrieval of the clamshell with a Dormia Basket was performed safely and the patient was discharged uneventfully on the day of the procedure.

Keywords: Foreign body; Retrieval

INTRODUCTION

Foreign body ingestion in the pediatric population usually occurs by accident. In adults, the most common causes are strictures of the gastrointestinal tract, gastrointestinal motility disorders, psychiatric disorders, mental retardation, false teeth, or impairment caused by alcohol, as well as by those seeking some secondary gain in accessing a medical facility1, 2). Most small foreign bodies will pass spontaneously through the entire alimentary tract and out in the feces. However, 10% to 20% of cases will not pass physiologic or pathologic strictures of the esophagus and will require intervention3). Removal with a flexible endoscope is preferred because of its low morbidity rate, reduced cost, and the ability to diagnose other diseases during the procedure. Foreign body impaction in the duodenum is very rare, between 0 (0%) to 5 (2.5%) in population studies4-8). Here we report the case of a clamshell impacted in the second duodenal portion, resulting in a clinical presentation mimicking a biliary stone.

CASE REPORT

A 60-year-old man with no previous abdominal complaints, dementia, or psychological disease, presented to our outpatient internal medicine department with a one-day history of abdominal pain. The pain was initially localized to the epigastrium, weakening in intensity as time went on. There was no nausea, vomiting, febrile or chilly sensations, or diarrhea. A physical examination revealed no localized tenderness in the abdomen and a temperature of 37℃. Laboratory tests indicated a slightly elevated white cell count of 11,130/mm3 with 78.5% neutrophils, elevated aspartate aminotransferase/alanine aminotransferase levels (52/44 IU/L), and normal serum amylase (86 U/L). Urinalysis and other laboratory data were within normal limits. An abdominal computed tomography scan showed a mild dilatation of the common bile duct, but no prominent obstructive lesion was seen. The computed tomography scan also showed a 3×2-cm calcific shadow in the second portion of the duodenum (Figure 1). An abdominal ultrasonography revealed an echogenic lesion in the duodenum (Figure 2). An arch-like echogenic rim and posterior acoustic shadowing of the lesion gave it the appearance of a stone originating from the biliary tree. Upper gastrointestinal endoscopy revealed a broken piece of clamshell in the second portion of the duodenum (Figure 3). Endoscopic retrieval of the clamshell by a Dormia Basket was performed safely (Figure 4, 5) and the patient was discharged neventfully on the day of the procedure.

Figure 1

CT demonstrates an ovoid high-density lesion (black arrows) in the third portion of the duodenum (white arrows).

Figure 2

Ultrasonography shows an intraluminal arch-like echogenic lesion (arrowheads) with a posterior shadow in the duodenum (arrows) on the transverse plane.

Figure 3

A broken piece of clamshell was discovered in the second portion of the duodenum.

Figure 4

Endoscopic retrieval of the clamshell with a Dormia Basket.

Figure 5

The broken piece of clamshell.

DISCUSSION

Ingestion of a foreign body is commonly encountered in children, adults with intellectual impairment, psychiatric illness or alcoholism, and elderly patients with dental prosthetics9, 10), but foreign body impaction in the duodenum is rare. According to a large study in China by Li et al11), a duodenal foreign body was reported in only 50 cases (4.6%) among the 1088 cases with foreign bodies in the upper GI tract. Most of these cases involved small, smooth objects, such as metallic pieces and glass balls. In general, objects wider than 2 cm do not pass through the pylorus and tend to lodge in the stomach, while objects longer than 5 cm tend to get caught in the duodenal sweep12, 13). The broken piece of clamshell in the present case was 2 cm in diameter and 3 cm in length, with a pointed edge. Objects that lodge in the gastric lumen often remain there for long periods without adverse consequences14). Watchful waiting is generally justified and may include administration of emetics, laxatives, or spasmolytics, depending on the type and site of object12). However, perforation is always a potential complication when sharp objects are ingested. Sharp objects that lodge in the same place for more than 2 to 3 days15) or objects in the stomach that have not moved for more than 5 to 6 days16) are unlikely to pass and should be removed endoscopically. Up to 15% to 35% of sharp and pointed foreign bodies ingested penetrate the wall of the gastrointestinal tract17) and should be removed by gastrostomy18). A sharp or pointed foreign body in the stomach or duodenum found during an endoscopic evaluation should be removed, even if the patient is asymptomatic. Usually, adults that ingest pointed objects are prisoners or psychiatric patients, and carry a higher complication rate and surgical rate than for accidental ingestion13).

In this case, the patient had no psychological disease and was not aware that he had eaten the clamshell. As a result, the diagnosis before performing upper gastrointestinal endoscopy was a gall stone in the duodenum, based on abdominal imaging. Endoscopic removal of foreign bodies requires skilled endoscopists and accessories such as snares, dormia baskets, or strong-toothed graspers. Commercial accessories developed specifically for removing foreign objects are also available-for example, soft-latex protector hoods19) and overtubes. Endoscopic retrieval of sharp objects is accomplished with the retrieval forceps (rat-tooth, biopsy, or alligator jaws) or a snare. The risk of mucosal injury during sharp-object retrieval can be minimized by orienting the object with the point trailing during extraction with an overtube. In this case, the small internal diameter of the overtube (11 to 15 mm) prevented the removal of the clamshell. Improved diagnostic and therapeutic modalities can now reduce the rate of morbidity and mortality associated with foreign body ingestions. However, it appears that the clinician must still maintain a high degree of suspicion and a prudent management plan when the possibility of foreign body impaction in the duodenum exists.

References

1. Blaho KE, Merigian KS, Winbery SL, Park LJ, Cockrell M. Foreign body ingestions in the Emergency Department: case reports and review of treatment. J Emerg Med 1998. 1621–26. 9472755.
2. Kamal I, Thompson J, Paquette DM. The hazards of vinyl glove ingestion in the mentally retarded patient with pica: new implications for surgical management. Can J Surg 1999. 42201–204. 10372016.
3. Davidoff E, Towne JB. Ingested foreign bodies. N Y State J Med 1975. 751003–1007. 1056525.
4. Kang YS, Jung JH, Chae KH, Heo WS, Kim YS, Kim SH, Sung JK, Lee BS, Jeong HY. Endoscopic treatment of foreign bodies in the upper gastrointestinal tract. Korean J Gastrointest Endosc 2005. 31135–139.
5. Park JH, Park CH, Park JH, Lee SJ, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS, Kim SJ. Review of 209 cases of foreign bodies in the upper gastrointestinal tract and clinical factors for successful endoscopic removal. Korean J Gastroenterol 2004. 43226–233. 15100486.
6. Shin WC, Shin SM, Kim YH, Kim KY. Endoscopic foreign body extraction of upper gastrointestinal tract. Korean J Gastrointest Endosc 1994. 14171–174.
7. Lee MS, Ra DH, Kim JH, Cho SW, Shim CS. A review of the endoscopic extraction in 52 cases of the upper gastrointestinal foreign bodies. Korean J Gastrointest Endosc 1990. 1047–52.
8. Kim HJ, Lee OJ, Min HJ, Kang DH, Lee EJ, Lee JH, Kim TH, Jung WT, Cho JH. Endoscopic treatment of esophageal foreign bodies in adult: management of 257 cases. Korean J Gastrointest Endosc 2004. 2951–57.
9. Selivanov V, Sheldon GF, Cello JP, Crass RA. Management of foreign body ingestion. Ann Surg 1984. 199187–191. 6696536.
10. Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingested foreign bodies of the gastrointestinal tract: retrospective analysis of 542 cases. World J Surg 1996. 201001–1005. 8798356.
11. Li ZS, Sun ZX, Zou DW, Xu GM, Wu RP, Liao Z. Endoscopic management of foreign bodies in the upper-gastrointestinal tract: experience with 1088 cases in China. Gastrointest Endosc 2006. 64485–492. 16996336.
12. Webb WA. Management of foreign bodies of the upper gastrointestinal tract. Gastroenterology 1988. 94204–216. 3275566.
13. Chang JJ, Yen CL. Endoscopic retrieval of multiple fragmented gastric bamboo chopsticks by using a flexible overtube. World J Gastroenterol 2004. 10769–770. 14991959.
14. Roark GD, Subramanyam K, Patterson M. Ingested foreign material in mentally disturbed patients. South Med J 1983. 761125–1127. 6351266.
15. Webb W. Management of foreign bodies of the upper gastrointestinal tract. Gastroenterol 1988. 94204–216.
16. Stack LB, Munter DW. Foreign bodies in the gastrointestinal tract. Emerg Med Clin North Am 1996. 14493–521. 8681881.
17. Rosch W, Classen M. Fibroendoscopic foreign body removal from the upper gastrointestinal tract. Endoscopy 1972. 4193–197.
18. Bakaleinik M. Foreign bodies of the gastrointestinal tract, surgical considerations. Mil Med 1989. 15411–14. 2493598.
19. Bertoni G, Sassatelli R, Conigliaro R, Bedogni G. A simple latex protector hood for safe endoscopic removal of sharp-pointed gastroesophageal foreign bodies. Gastrointest Endosc 1996. 44458–461. 8905368.

Article information Continued

Figure 1

CT demonstrates an ovoid high-density lesion (black arrows) in the third portion of the duodenum (white arrows).

Figure 2

Ultrasonography shows an intraluminal arch-like echogenic lesion (arrowheads) with a posterior shadow in the duodenum (arrows) on the transverse plane.

Figure 3

A broken piece of clamshell was discovered in the second portion of the duodenum.

Figure 4

Endoscopic retrieval of the clamshell with a Dormia Basket.

Figure 5

The broken piece of clamshell.