A Foreign Body (Chicken Bone) in the Rectum Causing Extensive Perirectal and Scrotal Abscess: Report of a Case* C~ZAR A. MOREIRA, M.D., SOBSAN ~r ANTHONY R. GENNARO, M.D.
M.D.
From Temple University Health Sciences Center, Philadelphia, Pennsylvania
PERIRECTAL ABSCESSEScaused by foreignbody perforation have been reported, but extensive necrotizing abscess formation caused by perforation by chicken bone is extremely rare. This case is being reported because of its peculiarity of being caused by a chicken bone and the gravity and extensiveness of the process (necrotizing infection extending from the left perianal region and scrotum to the left inguinal and flank region). Although 10 to 20 per cent of ingested foreign bodies fail to pass through the entire gastrointestinal tract, fewer than 1 per cent cause perforation, s McPherson e t al., s emphasized the frequency of associated use of dentures, as in this case, in cases of foreign-body perforation of the intestinal tract. T h e reason is that patients do not feel sharpness or hardness as they would with normal palates. MacManus? in 1941, reported 95 cases of gastrointestinal perforation by foreign bodies. Metallic objects such as pins and wire were responsible for 46 per cent of the perforations, and animal bones, including those of fish, chicken, and rabbits, also accounted for 46 per cent. 2 Wood splinters, toothpicks, and pencils caused the remain* Received for publication November 4, 1974. Address reprint requests to Dr. Moreira, 3401 North Broad Street, Philadelphia, Pennsylvania 19140.
Fro. 1. Extensive abscess of the perineum and scrotum, with extension to the right and left flanks (as shown on shaded area).
FIG. 2. Abscess and crepitation (shaded area) involving the anterior abdominal wall.
ing 8 per centJ In 1970, Maleki and Evans 4 collected reports of 300 cases of intraabdominal abscesses secondary to perforation of the gastrointestinal tract. In 1971, Berk and Reit t reported two cases of intra-
407 Dis. Col. & Rect. July-Aug. 1975
Volume 18 Number 5
408
MOREiRA, ET AL.
Dis. Col. & Reet. J'uly-Aug, 1975
a b d o m i n a l abscesses c a u s e d by p e r f o r a t i o n of t h e g a s t r o i n t e s t i n a l t r a c t by c h i c k e n b o n e s . O n e b o n e p e r f o r a t e d at t h e a r e a of a d i v e r t i c u l u m in t h e s i g m o i d c o l o n . T h e m o s t c o m m o n sites of p e r f o r a t i o n h a v e b e e n in the i l e o c e c a l r e g i o n , w i t h a prep o n d e r a n c e in t h e a p p e n d i x a n d M e c k e l ' s diverticulttm. 3 W a r d - M c Q u a i d 6 r e p o r t e d t w o cases of i n t e s t i n a l p e r f o r a t i o n by r a b b i t b o n e s . I n one patient perforation of t h e r e c t u m caused pelviperitonitis and death. Report
Flc. 3. Extensive edema and necrosis of the periaual region and scrotum (picture from day of admission),
of a Case
A 31-year-old Negro man was seen in the emergency room on August 7, 1974, complaining of pain and swelling around the anal canal and scrotum. He also described a purulent drainage from the rectum for two days prior to admission. He was severely ill, with a temperature of 102 F, and was tmabte to sit or walk. Examination otherwise was unremarkable except for the proctogenital region. There was extensive edema of the perianal region and scrotum, with crepitation of both inguinal regions and the left flank (Figs. I and 2). A diagnosis of extensive perirectal abscess, extending to the scrotum and anterior abdominal wall, was made (Fig. 3). The laboratory tests were normal except for a leukocyte count of 17,500, fasting blood sugar of 198 mg/100 ml and hemoglobin of 9.2 g/100 ml.
FIG. 4. Left perianal and both scrotal spaces opened.
CHICKEN BONE CAUSING ABSCESS
Volume 18 Number 5
T h e patient was operated, upon on the day of admission. Extensive resection of the gangrenous skin and subcutaneous tissue was performed. This included the left perineal region, scrotum, right and left inguinal areas and left flank (Fig. 4). An orifice of drainage was identified at the left lateral rectal wall about 5 cm from the anal verge. Bacteriology of the wound drainage showed Proteus mirabilis, with some alpha-streptococci, group D. Treatment with gentamicin and clindamycin was started. Also, debridement of necrotic tissue was performed daily either at the bedside or in the operating room. Wounds were irrigated daily with a 0.5 per cent solution of oxychlorosene.t On the first postoperative day, at the time of the dressing change, a piece of what appeared to be sharp bone was found deep inside the perirectal wound. T h e specimen was sent to the Pathology Department to confirm the diagnosis (Fig. 5). A retrospective history was taken from the patient, who recalled chewing chicken bones a week before admission. Interestingly, he also commented that several years previously his father had had a perirectal abscess caused by perforation of the rectum by a chicken bone. T h e postoperative course was uneventful, and five weeks after the first procedure all wounds were completely healed, except that the scrotum required a skin graft procedure. Summary A case o~ f o r e i g n - b o d y p e r f o r a t i o n
of t h e
rectum with extensive necrotizing fasciitis is p r e s e n t e d a n d t h e l i t e r a t u r e b r i e f l y rev i e w e d . T h e p e c u l i a r i t y of t h e case w a s brought out because of the nature of the foreig n body (chicken bone) and the extensiveness of the process. The increased risk of s w a l l o w i n g a f o r e i g n b o d y if d e n t u r e s a r e w o r n is p o i n t e d o u t . t Clorpactin XCB, Guardian Chemical Corporation.
FIG. 5. cavity.
409
Chicken bone removed from the abscess
References 1. Berk RN, Reit RJ: Intra-abdominal chickenbone abscess. Radiology 101:311, 1971 2. Gunn A, Cantal MB: Intestinal perforation due to swallowed fish or meat bone. Lancet 1:125, 1966 3. MacManus JE: Perforations of the intestine by ingested foreign bodies: Report of two cases and review of the literature. Am J Surg 53: 393, 1941 4. Maleki M, Evans WE: Foreign-body perforation of the intestinal tract: Report of 12 cases and review of the literature. Arch Surg 101:475, 1970 5. McPherson R C , Karlan M, Williams RD: Foreign body perforation of the intestinal tract. Am J Surg 94:564, 1957 6. Ward-McQuaid JN: Perforation of the intestine by swallowed foreign bodies with a report of two cases of perforation by rabbit bones. Br J Surg 39:349, 1952
M.D.
From Temple University Health Sciences Center, Philadelphia, Pennsylvania
PERIRECTAL ABSCESSEScaused by foreignbody perforation have been reported, but extensive necrotizing abscess formation caused by perforation by chicken bone is extremely rare. This case is being reported because of its peculiarity of being caused by a chicken bone and the gravity and extensiveness of the process (necrotizing infection extending from the left perianal region and scrotum to the left inguinal and flank region). Although 10 to 20 per cent of ingested foreign bodies fail to pass through the entire gastrointestinal tract, fewer than 1 per cent cause perforation, s McPherson e t al., s emphasized the frequency of associated use of dentures, as in this case, in cases of foreign-body perforation of the intestinal tract. T h e reason is that patients do not feel sharpness or hardness as they would with normal palates. MacManus? in 1941, reported 95 cases of gastrointestinal perforation by foreign bodies. Metallic objects such as pins and wire were responsible for 46 per cent of the perforations, and animal bones, including those of fish, chicken, and rabbits, also accounted for 46 per cent. 2 Wood splinters, toothpicks, and pencils caused the remain* Received for publication November 4, 1974. Address reprint requests to Dr. Moreira, 3401 North Broad Street, Philadelphia, Pennsylvania 19140.
Fro. 1. Extensive abscess of the perineum and scrotum, with extension to the right and left flanks (as shown on shaded area).
FIG. 2. Abscess and crepitation (shaded area) involving the anterior abdominal wall.
ing 8 per centJ In 1970, Maleki and Evans 4 collected reports of 300 cases of intraabdominal abscesses secondary to perforation of the gastrointestinal tract. In 1971, Berk and Reit t reported two cases of intra-
407 Dis. Col. & Rect. July-Aug. 1975
Volume 18 Number 5
408
MOREiRA, ET AL.
Dis. Col. & Reet. J'uly-Aug, 1975
a b d o m i n a l abscesses c a u s e d by p e r f o r a t i o n of t h e g a s t r o i n t e s t i n a l t r a c t by c h i c k e n b o n e s . O n e b o n e p e r f o r a t e d at t h e a r e a of a d i v e r t i c u l u m in t h e s i g m o i d c o l o n . T h e m o s t c o m m o n sites of p e r f o r a t i o n h a v e b e e n in the i l e o c e c a l r e g i o n , w i t h a prep o n d e r a n c e in t h e a p p e n d i x a n d M e c k e l ' s diverticulttm. 3 W a r d - M c Q u a i d 6 r e p o r t e d t w o cases of i n t e s t i n a l p e r f o r a t i o n by r a b b i t b o n e s . I n one patient perforation of t h e r e c t u m caused pelviperitonitis and death. Report
Flc. 3. Extensive edema and necrosis of the periaual region and scrotum (picture from day of admission),
of a Case
A 31-year-old Negro man was seen in the emergency room on August 7, 1974, complaining of pain and swelling around the anal canal and scrotum. He also described a purulent drainage from the rectum for two days prior to admission. He was severely ill, with a temperature of 102 F, and was tmabte to sit or walk. Examination otherwise was unremarkable except for the proctogenital region. There was extensive edema of the perianal region and scrotum, with crepitation of both inguinal regions and the left flank (Figs. I and 2). A diagnosis of extensive perirectal abscess, extending to the scrotum and anterior abdominal wall, was made (Fig. 3). The laboratory tests were normal except for a leukocyte count of 17,500, fasting blood sugar of 198 mg/100 ml and hemoglobin of 9.2 g/100 ml.
FIG. 4. Left perianal and both scrotal spaces opened.
CHICKEN BONE CAUSING ABSCESS
Volume 18 Number 5
T h e patient was operated, upon on the day of admission. Extensive resection of the gangrenous skin and subcutaneous tissue was performed. This included the left perineal region, scrotum, right and left inguinal areas and left flank (Fig. 4). An orifice of drainage was identified at the left lateral rectal wall about 5 cm from the anal verge. Bacteriology of the wound drainage showed Proteus mirabilis, with some alpha-streptococci, group D. Treatment with gentamicin and clindamycin was started. Also, debridement of necrotic tissue was performed daily either at the bedside or in the operating room. Wounds were irrigated daily with a 0.5 per cent solution of oxychlorosene.t On the first postoperative day, at the time of the dressing change, a piece of what appeared to be sharp bone was found deep inside the perirectal wound. T h e specimen was sent to the Pathology Department to confirm the diagnosis (Fig. 5). A retrospective history was taken from the patient, who recalled chewing chicken bones a week before admission. Interestingly, he also commented that several years previously his father had had a perirectal abscess caused by perforation of the rectum by a chicken bone. T h e postoperative course was uneventful, and five weeks after the first procedure all wounds were completely healed, except that the scrotum required a skin graft procedure. Summary A case o~ f o r e i g n - b o d y p e r f o r a t i o n
of t h e
rectum with extensive necrotizing fasciitis is p r e s e n t e d a n d t h e l i t e r a t u r e b r i e f l y rev i e w e d . T h e p e c u l i a r i t y of t h e case w a s brought out because of the nature of the foreig n body (chicken bone) and the extensiveness of the process. The increased risk of s w a l l o w i n g a f o r e i g n b o d y if d e n t u r e s a r e w o r n is p o i n t e d o u t . t Clorpactin XCB, Guardian Chemical Corporation.
FIG. 5. cavity.
409
Chicken bone removed from the abscess
References 1. Berk RN, Reit RJ: Intra-abdominal chickenbone abscess. Radiology 101:311, 1971 2. Gunn A, Cantal MB: Intestinal perforation due to swallowed fish or meat bone. Lancet 1:125, 1966 3. MacManus JE: Perforations of the intestine by ingested foreign bodies: Report of two cases and review of the literature. Am J Surg 53: 393, 1941 4. Maleki M, Evans WE: Foreign-body perforation of the intestinal tract: Report of 12 cases and review of the literature. Arch Surg 101:475, 1970 5. McPherson R C , Karlan M, Williams RD: Foreign body perforation of the intestinal tract. Am J Surg 94:564, 1957 6. Ward-McQuaid JN: Perforation of the intestine by swallowed foreign bodies with a report of two cases of perforation by rabbit bones. Br J Surg 39:349, 1952
