Brought to you by
ECR 2012 / C-1334
Foreign bodies: What a wonderful world!
Congress: ECR 2012
Poster No.: C-1334
Type: Educational Exhibit
Keywords: Foreign bodies, eLearning, CT, Conventional radiography, Emergency, Abdomen
Authors: L. Garcia-Ferrer, R. Garcia Garcia, M. D. MONEDERO, A. González-Cruz Soler, E. Cascón Sánchez, E. Blanco Pérez; Valencia/ES
DOI:10.1594/ecr2012/C-1334

Imaging findings OR Procedure details

FB mainly are found in the ER radiology department, with radiography. When we have an image sugesting a FB, the first question is: real or fake?. In order to answer, it’s important to obtain the adequate proyections (Fig. 1) and look at the patient (Fig. 2) because radiopaque marks are frequent in underclothes.

 

Fig. 1: Anteroposterior and lateral chest x-ray. Patient received an aggression with bistoury.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 2: Abdominal x-ray. False FB image due to underclothes.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

 

FB ingestions:

They represent 80% of the FB.

An important clue is the upper third of the esophagus as it can cause confusion with airway. In order to know the proper diagnosis is important to know the anatomy: airway has a mayor anteroposterior diameter and is positioned anterior to the esophagus, because of that FB will be flat in lateral proyections (Fig. 3, 4).

 

Fig. 3: Cervical CT, multiplanar reconstruction which shows elongated anteroposterior disposition of the airway.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 4: AP and lateral x-ray. FB allocated in the airway. It was a psychiatric patient that swallowed a metallic piece used for physical restrain.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

Esophagus is a muscular estructure able to accept bigger FB due to it’s distension capacity, so FB will be flat in AP proyections (Fig. 5, 6).

 

Fig. 5: Cervical CT, multiplanar reconstruction which shows the posterior position of the esophagus to the airway.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 6: AP and lateral x-ray. FB allocated in the esophagus, it was a coin.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

Also, clinical presentation is important but not pathognomonic as disphonia or cought can be caused by FB lodged in esophagus with maintained spasm of the cricopharingeal muscle, irritation and edema that extends to glotis (Fig. 7).

 

Fig. 7: Pins allocated in proximal esophagus and with local edema extending to the glotis (see left image).
References: Courtesy Dr. Hector Cortina. Radiology service, children hospital, La fe. Valencia-Spain.

 

Other areas of interest are the lower esophagus, pylorus and ileocecal valve.

In our center, a FB with no clinical symptoms is treated with observation and x-ray (Fig. 8).

 

Fig. 8: Abdominal x-rays. Follow-up of a patient who swallowed a nail. It went throught gastrointestinal tract without complications.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

Endoscopy is used in case of multiple FB, big ones (Fig. 9) or sharp objects with risk of laceration and also in cases of FB lodged more than 48h (24h in esophagus).

 

Fig. 9: Endoscopy of a FB due to its morphology.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

When the object goes beyond duodenum and the patient is asymptomatic, observation is the rule. If there is no succes with endoscopy and because of symptoms or it’s morphology is necessary to extract the FB, patient goes to surgery (Fig. 10).

 

Fig. 10: Multiple FB in a prisoner, that required surgery to extract them all.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 11: Look at the detail. The nail clipper es enveloped with plastic in order to avoid lesions from the sharp borders.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

Psychiatric patients and prison people use FB in order to be transferred to hospital. Usually they have multiple objects and sharp ones. It’s important knowing that they “protect” the dangerous borders with plastics or papers (Fig. 11). Also, globes are used to facilitate the swallowing of group of objects (Fig. 12). When multiple metallic object, magnets are used to join them.

 

Fig. 12: Psichiatric patient who underwent endoscopy due to multiple FB. They were inside latex gloves.
References: Courtesy Radiology Service Hospital de la Ribera, Alzira-Spain.

 

Here is a list of frequent ingested FB:

-Thumbtack (Fig. 13).

Fig. 13
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

-Rings (Fig 14)

Fig. 14
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Dentures: Older patients have lesser sensibility in the mouth because the cronical use of false teeth. Also, in case of dementia, the risk of swallowing the denture exist (Fig.15).

Fig. 15
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Pens (Fig. 16).

Fig. 16: Abdominal x-ray and CT. Because of its long silhouette, pens usually don’t go beyong duodenum and require endoscopy.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Lighters (Fig. 17).

Fig. 17: Abdominal x-ray of a psychiatric patient who swalled lighters in the recovery after an abdominal surgery because previous FB.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Batteries: Because their size, they don’t cause problems of lodging in the gastrointestinal tract. The important fact is that despite mercury is no longer used, they have a variety of alkaline agents and metals with corrosive action. A roture of the capsule of the battery entails risk of perforation and chemical peritonitis (Fig. 18).

Fig. 18: Abdominal x-ray. It is important to diferentiate between button bateeries and coins. The first ones have the center thinner that the borders showing a double density.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Wires (Fig. 19).

Fig. 19
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Nails: Remember that usually they are ingested by psychiatric or prison people that put them in groups inside of plastics or united with Scotch tape. Sometimes envelope fails and a few nails get free (Fig. 20).

Fig. 20: Abdominal x-ray of different patients with ingested nails. The left patient got free nails because of bad envelopin of the package.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Pins (Fig. 21).

Fig. 21
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Coins: almost exclusive in children (Fig. 22).

Fig. 22
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Keys (Fig. 23).

 

Fig. 23
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Toys (Fig 24).

Fig. 24
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Screws (Fig. 25)

Fig. 25
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Cutlery (Fig. 26)

Fig. 26
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 -Hairgrip (Fig 27)

Fig. 27
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Bracelet (Fig 28) 

Fig. 28
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Multiple FB (Fig. 29-32)  

Fig. 29: Abdominal x-ray of a psychiatric patient with recent abdominal surgery (*) that swallowed new objects and had to be operated again. We can see a metallic bar, lighters and batteries.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

Fig. 30: Prisoner who ingested a nail clipper with sprung bed base. Endoscopy only could remove part of the material and the patient was submitted for surgery.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 31: Abdominal x-ray od a psychiatric patient with history of multiple FB ingestion. We can see wires, keyring, batteries and a hanger.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 32: Razor blades are frequent in prison people. They are ingested in its envelope (not seen in x-ray).
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

Other locations: In this group we’ll include FB inserted in the organism by accident or hurting oneself. FB with sexual intention, aesthetics, drugs and iatrogenia also will be comented.

 

1.- Suicide attempt: Almost exclusivelly in psychiatric patients, sometimes trying to to attract attention, and sometimes real attempts.

-The most frequent findings are sharp objects as knives. Lesions can be everywhere (Fig 33)

Fig. 33: A man was sent to hospital ER because he hurt himself in the head with a knife. The patient had no neurology symptoms and although with metal artifacts a head CT showed no hemorrhage. Neurosurgeons extracted the knife without complications.
References: Courtesy of Doctors Laura Trilles and Natalia Madroñal. Radiology Service, Hospital La fe. Valencia-Spain.

-Mercury: It was possible to find it in thermometers (until it was forbidded and changed for alcohol) and sphygmomanometers. It evaporates at room temperature and has little toxicity in skin contact o gastrointestinal ingestion. When evaporates, is toxic with inhalation. In a very rare cases it can be seen in blood vessels causing embolisms (Fig 34).

Fig. 34: A 42 year-old man was sent to hospital ER because suicide attempt. In the physical exploration an eritema in the arm was seen. X.ray reveled a raiopaque substace in antecubital veins with embolism y lung arteries (*), liquid level in right ventricle (big arrow) and embolism in mesenteric vessels (little arrow).
References: Courtesy of Dr. Roberto Llorens. Radiology Service, Hospital La fe. Valencia-Spain. (Partially published in: Lorenzo MJ., Cases E., Bravo J et al. Pulmonary embolism caused by elemental mercury. Arch Bronconeumol 2007:43(10)585-587)

2.- Sexual accidents: We can find all kind of objects, with specific design for sex pleasure or.. not. The most frequent way is the rectum.

-Vibrators (Fig 35).

Fig. 35: Manual (left) or mechanical (right) vibrators.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Wires (Fig 36, 37).

Fig. 36: A 70 year-old woman who attempted sexual stimulation inserting a wire in the vagina. The wire filled uterus and she underwent surgery.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 37: Wire in the urethra (penis). This case was a psychiatric patient.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Bottles (Fig 38)

 

Fig. 38
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Blunt instruments (Fig 39)

Fig. 39: Abdominal x-ray of a 40 years old man who was assisted in a rectal FB. He said that used a handle of a shears because of constipation... Despite the height of the object, there was no complication.
References: Courtesy Dr. MD Monedero. Radiology service, Complejo Hospitalario Universitario de Albacete (CHUA)-Spain.

 

3.- Illegal substances: In order to smuggle drugs, these are inserted in plastic bags that are swallowed or put in rectum. The morfology in conventional radiology (abdominal x-ray) with air within or delineating the packs is enough to make the diagnosis, although sometimes CT is needed because of complications as intestinal obstructions. There are three nomenclatures in the literature:

-Body packer: People paid to transport drugs. Usually there is a big quantity of drug, lethal in case of breaking a pack. Because of the amount, they prefer to swallow, so the drug will be found in stomach or intestinal loops (Fig 40, 41).

Fig. 40: 48 year-old man with diabetes mellitus type 1. He consulted because of 48h abdominal pain and referred ingestion in the last weeks of Khakis (fruit with high fiber content). Symptoms were compatible with intestinal occlusion and the abdominal x-ray revealed a stomach full of mixture air-high density substance, dilated intestinal loops and impacted material in ileal loop (Arrow). CT confirmed the diagnosis of occlusion and showed well-delineated high density substance surrounded by air (suspected ingestion of drugs). He denied ingestion of drugs packages. Surgery was done and confirmed body packer. Beware, some of them know the clinical diagnosis of Bezoar.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 41: Images of surgery. 36 packets were retrieved. It was liquid cocaine.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Body stuffer: Drug dealers that do a complusive ingestion of drugs before to be arrested. Drug quantity is minor that body packers, not enough to be a lethal dosis.

-Body pusher: It’s a kind of body packer that uses rectal o vaginal cavities (Fig 42)

Fig. 42: Young man arrested because of suspected drug smuggle. Abdominal x-ray confirmed two FB in rectum.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

4.- Aesthetics reasons: Prosthesis with aesthetics reasons (cosmetic surgery) is an increasing field of cosmetic surgery. They are done with the intention to enhance or improve a part of the human body. Because this kind of medicine is not supperted by the national healt insurance system, and the price (thousands of euros), people with low economy and cultural level look for another “solutions”. These ones usually consist in direct injection of non-medical silicone. The results tend to be a disater with infections and requirement of surgery.

-Penis (Fig 43). 

Fig. 43: A 32 year-old man that injected himself silicone in the penis. He developed chronic infection with fistulas that required several surgical debridements. MRI T2W axial and Stir sagittal images that show hyperintense silicone (arrows) in a swollen penis.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Breast: (Fig 44).

Fig. 44: 23 year-old woman that got fluid silicone injected in her breast. The result was an enormous deformation of the breast. She's waiting for repairing surgery. Silicone is depicted as hiperdense (in mamography) and anechoic (in ultrasonography) amorphous substance.
References: Courtesy of Dr. J. Palao. Unit of Breast imaging. Radiology Service. CHGUV. Spain.

-Face (fig 45).

 

Fig. 45: Casual finding in facial CT of silicone in cheeks (*).
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

5.- Accidents: Traumatic introduction of FB with non-voluntary intention.

-Nails: Usually the result of working with mechanical hammers (instrument that throw nails, used mainly in carpenter’s workshop). The nail can be stuck in the abdominal cavity, requiring surgery (Fig 46); or can be found in any part of the body (Fig 47, 48).

Fig. 46: Work-related accident with a nail. It was thrown while the patient was checking the hammer, and penetrated into the abdomen. A CT showed a close relation of the nail (*) with a jejunum loop with no sign of perforation. Surgery extracted the FB and confirmed no complications.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 47: Work-related accident. Nail in the calf.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 48: Accident with a nail that was thrown at the head of the patient. It did not penetrated bone and just a minor cure was required.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Thorns/Prickles: they are not seen in x-ray because their low density, so ultrasonography is required to find them (Fig 49).

Fig. 49: Palm tree prickle in the wrist. Ultrasonography located it beside radial artery. Minor surgery was done without complication.
References: Courtesy. Dr. A. Alonso. Radiology service. Centro de Rehabilitación de Levante. Valencia-Spain.

-Glass: more frequent in summer, when people wears light shoes. Glass is always visible in x-ray (Fig 50).

Fig. 50: A piece of glass in the heel. The patient referred an accident with a bottle of glass a few days before. Physical exam revealed minor injury in the heel and suspected FB was confirmed.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

6.- Firearms: Bullets are a rare finding in our country due to the requirement you need to fullfill in order to obtain a licence. Pellets are no so rare because the regulatoty laws do not control these weapons.

-Bullets: We can find bullets as a casual finding in old people (Fig 51)

Fig. 51: 80 year-old man consulting because of dyspnea. Chest x-ray revealed a bulled in liver (arrow). He fought in the spanish civil war where he was injured.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

that fought in war and got wounded. The most frequent causes in emergency rooms are aggressions (Fig 52).

Fig. 52: 27 year-old woman assisted in Emergency Room because shot wound. Chest x-ray: The bullet can be seen posterior to the sternal bone (arrows), with mediastinum widening. Surgery extracted the bullet and confirmed haemomediastinum secondary to the bullet.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Pellets: They are frequent and can be seen in any part of the body (Fig 53). As it is easier to get these firerarms, sometimes people use them to attempt suicide (Fig 54).

Fig. 53: Hunting accident. Pellets in the axilla.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

Fig. 54: A 36 year-old psychiatric patient that attempted to suicide with a firearm. He aimed from below, but too anteriorly so.. the shot disfigured his face. Only one pellet got to the frontal lobe. He survived and required multiple surgery treatment to make a partial reconstruction of the face.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

7.- Iatrogenic procedures: Not to be seen as a show, they have the utility to make us learn from our mistakes or to know the posible complications of treatments so we can be alert in case of early symptoms.

-Gossypiboma: In order to avoid this complication, surgical sponges are counted before and after the surgery. Also, they have metallic markers so can be seen in radiological studies. Unfortunatelly, a sponge can be left. Clinical presentation vary from asymptomatic patients to granulomatoid reactions against the FB with abscesses (Fig 55).

Fig. 55: Five days after chilbirth (cesarean section), this woman consulted with abdominal pain and high grade fever. Abdominal x-ray showed an image compatible with surgical sponge left in abdominal cavity (Gossypiboma). CT confirmed the diagnosis.
References: Courtesy Dr. MD Monedero. Radiology service. Complejo Hospitalario Universitario de Albacete (CHUA)-Spain.

-Surgical Valves (Fig 56)

Fig. 56
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Urinary catheter: In oncology patients with pelvis neoplasias, these catheters can cause complications as fistulas (Fig 57, 58).

Fig. 57: 59 year-old man with stage IV rectal cancer (sigmoid) that infiltrated prostate. After inserting urinary catheter, fecaluria was noted. A pelvic MRI T2W high resolution sequences in axial sagittal and axial views showed fistula due to perforation of the prostate urethra with end of the tube in rectum.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES
Fig. 58: 61 year old man with stage IV colonic cancer (liver metastasis noticeable in CT image). After inserting urinary catheter fecaluria was noted. CT showed air bubbles outside the bladder, with the end of the catheter just under the neoplasia. A pelvic MRI with T1W enhanced images confirmed the suspected fistula.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Nasogastric tube: (Fig 59)

 

Fig. 59: A 73 year-old man with diagnosis of gastric cancer. He was underwent surgery with total gastrectomy. A week after removing the nasogastric tube, dysphagia persisted so an esophagogram was required. It showed part of the tube inside the esophagus. After endoscopy, the patient was asymptomatic.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

-Breakage of catheter: (Fig 60)

Fig. 60: 48 year-old man with a traumatic fracture secondary to a bike falling. He was treated with vertebroplasty and a control CT demonstrated breakage of the catheter used to fit the cement. As the patient was asymptomatic, no measure was done.
References: CT & MRI unit, ERESA, Consorcio Hospital General Universitario de Valencia - Valencia/ES

 

 

POSTER ACTIONS Add bookmark Contact presenter Send to a friend Download pdf
SHARE THIS POSTER
2 clicks for more privacy: On the first click the button will be activated and you can then share the poster with a second click.

This website uses cookies. Learn more