Colonic perforation resulting from ingested chicken bone revealing previously undiagnosed colonic adenocarcinoma: report of a case and review of literature
© McGregor et al; licensee BioMed Central Ltd. 2011
Received: 26 August 2010
Accepted: 18 February 2011
Published: 18 February 2011
An 86 year old male with a four-day history of nonspecific gastrointestinal symptoms was found on colonoscopy to have evidence of sigmoid colon obstruction and possible perforation. Emergent operative exploration revealed diffuse peritonitis, sigmoid perforation, adjacent dense adhesions, and a foreign body protruding through the perforated area. Pathologic examination showed the foreign body to be a sliver of bone consistent with chicken bone and the sigmoid subacute perforation to be associated distally with a circumferential ulcerated obstructing mass, microscopically seen to be transmurally infiltrating adenocarcinoma, signet-ring cell type. There was extensive acute and organizing peritonitis, 100% Escherichia coli was cultured from peritoneal fluid, and the patient died two days postoperatively with sepsis and hypotension. This appears to be the fifth reported case of colonic perforation resulting from foreign body perforation due to previously undiagnosed adenocarcinoma. The four previously reported cases were all deeply invasive adenocarcinoma of sigmoid colon, and the foreign bodies included three chicken/poultry bones and a metallic staple. These five cases are highly unusual examples of a potentially lethal malignant neoplasm being clinically revealed by a usually (but not always) innocuous event, the ingestion of a small foreign body.
Colonic perforation is most often secondary to extrinsic or intrinsic obstruction, but occasionally it may be due to other factors such as foreign bodies. Over 300 cases of bowel perforation caused by foreign bodies have been reported in the literature, with fish bones, chicken bones and dentures being the commonest objects, followed by toothpicks and cocktail sticks . Foreign body-associated perforation commonly occurs at the point of acute angulation and narrowing, and the most common site of perforation is the terminal ileum and colon, with an increased number of reports of perforation in association with Meckel's diverticulum, the appendix and diverticular disease [2, 3].
Reported cases of colon perforation resulting from foreign body and previously undiagnosed carcinoma
6.5 cm long circular ulcerated moderately differentiated adenocarcinoma without stenosis
pT3 N0 M0
Exophytic infiltrating moderately differentiated adenocarcinoma
pT4 N1 M0
Polypoid mass, adenocarcinoma
5.5 × 4.4 cm circumferential ulcerated mucinous/signet ring adenocarcinoma
pT3 N2 MX
Died 2 days postop from sepsis
An 86 year old male presented with a four-day history of abdominal pain, nausea, vomiting, and intolerance to oral intake. Physical exam demonstrated left lower, right lower and left upper quadrant tenderness, but clinical evidence of colonic obstruction and acute abdomen was not identified. Vital signs were temperature 98.5, pulse 86, respiration 20 and blood pressure 136/62. Laboratory data included WBC 6.4 K/cmm, neutrophils 87.5%, hemoglobin 11.5 g/dl and hematocrit 37.4%. Radiologic abdominal exam demonstrated a normal gas pattern, and ultrasound and CT scan studies were not indicated. Colonoscopy (preceded by midazolam and demarol medication) was performed for evaluation of iron deficiency, however, and showed evidence of sigmoid colon obstruction and possible perforation, including a mass with narrowing at 30 cm and a cavernous defect with whitish exudate. The patient underwent emergent operative exploration, which revealed diffuse peritonitis, a sigmoid perforation, adjacent dense adhesions, and a foreign body protruding through the perforated area. Sigmoid colon resection and end colostomy with Hartman's pouch was performed.
Microscopically, the colonic mass distal to the perforation, was a poorly differentiated adenocarcinoma, signet ring cell type (histologic grade 4), with invasion through the muscularis propria into subserosal adipose tissue (Figure 2C, D), and there were metastases in 20 of 35 pericolic lymph nodes (pathologic stage T3 N2 MX). The colonic perforation was found to be subacute, with extensive acute and organizing peritonitis. 100% heavy growth of Escherichia coli was cultured from peritoneal fluid. Postoperatively, the patient remained septic and hypotensive, and he expired two days later.
Colonic perforation is usually due to extrinsic or intrinsic obstruction, but occasionally other factors such as foreign bodies may be involved. We report here a case of sigmoid colon perforation which resulted from an ingested chicken bone penetrating the colonic wall due to obstruction by a previously undiagnosed sigmoid colonic adenocarcinoma. This appears to be the fifth reported case of colonic perforation resulting from foreign body perforation due to previously undiagnosed adenocarcinoma.
Table 1 outlines the basic specifics of these five cases. Not surprisingly, all of these obstructing colon cancers were large deeply invasive adenocarcinomas and their locations were the anatomically distal and relatively narrow sigmoid colon. The foreign bodies included 3 chicken/poultry bones (as in the present case 5) and a metallic staple. The clinical outcomes were full recovery (cases 1 and 2), postoperative death due to sepsis (case 5) and unknown (cases 3 and 4).
The above case report and four previous cases show the similarities among these five cases - highly unusual examples of a potentially lethal malignant neoplasm being clinically revealed by a usually (but not always) innocuous event, the ingestion of a small foreign body.
Written informed consent was obtained from the patient's next of kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Douglas H. McGregor is Professor of Pathology at the University of Kansas Medical Center and Director of Surgical Pathology at the Kansas City Veterans Affairs Medical Center, and he has been a manuscript reviewer for the World Journal of Surgical Oncology. Xiaoying Liu was Pathology Resident and Cytopathology Fellow at the University of Kansas Medical Center when this manuscript was conceived and developed, and she is currently Assistant Professor at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. Ozlem Ulusarac is Assistant Professor of Pathology at the University of Kansas Medical Center and Director of Microbiology/Immunology and Chemistry at the Kansas City Veterans Affairs Medical Center. Kimberly D. Ponnuru is Assistant Clinical Professor of Surgery at the University of Missouri - Kansas City and Staff Surgeon at the Kansas City Veterans Affairs Medical Center. Stephanie L. Schnepp was Surgery Resident at the University of Missouri - Kansas City at the time of the patient's surgery and currently practices general surgery with Bellevue Surgical Associates, Saint Louis, Missouri.
The authors thank Mr. Dennis Friesen for photographic assistance, Ms. Peggy Knaus for secretarial assistance, and Ms. Inga Barringer for translation assistance.
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