Acute abdominal pain, diagnostic laparoscopy showed multiple Intestinal perforation. During the surgery it was seen that the cause was multiple magnets conglomeration causing ischemia in the intestinal wall and perforation. The patient did not revieled the ingestion of foreign bodies.

1. Non-Traumatic Multiple
Intestinal Perforations
Case Presentation
Dr. Majd AlHaddadin, MBChB, MS, MRCS, FACS
Consultant General & Laparoscopic Surgeon
Al Hammadi Hospital – Nuzha – Riyadh- Saudi Arabia

2. Introduction
• Accidental ingestion of a foreign body together with food is a common
clinical problem at emergency care facilities.
• Voluntary ingestion of a foreign body is not common.
• Although most ingested foreign bodies pass through the gastrointestinal tract
without consequences within one week .
• In up to 1% of cases perforation occurs at some point in the gastrointestinal
tract.

3. Introduction
• Perforation of the gastrointestinal tract is more common if the foreign body
is elongated and sharp, like a fish bone, chicken bone, or toothpick, and
occurs mainly in the small intestine, at points of physiological angulation or
narrowing.
• The clinical presentation is varied and often poses a diagnostic challenge.
Patients generally do not report the ingestion of a foreign body, which delays
the diagnosis and creates confusion with other diagnostic possibilities.

4. Case Presentation
• A 15 year — old, with no past medical, surgical or physiological history
• ER visit on 18/oct/2021:
- lower abdominal pain of 4 days duration
- Low grade fever
- No improvement on analgesia
Physical examination:
Lower abdominal pain and tenderness, signs of localized peritonitis.

5. Relevant Investigations:
• Labs:
- Wbc 10.9 X 10^9/L Neutrophils: 90.8
- C-reactive protein 20 mg/L
• Abdomen US
RIF: tender on probing, appendix seen at the right iliac fossa with outer wall to wall
diameter about 8.9 mm with small free fluid collection & echogenic fat, there is tubular
echogenic structure seen at the right iliac fossa with posterior acoustic shadowing,
could be appendicolith.
???

6. Abdomen X Ray
Air - Fluid levels
Foreign Body ??

7. Decision:
• Ct scan abdomen : No
• Urgent diagnostic laparoscopy.
• Initial diagnosis: acute appendicitis.
• Consent for laparotomy and bowel resection obtained.
• Preoperative anesthesia assessment.

8. Diagnostic laparoscopy findings :
Conglomerated bowel loops

9. Jejunum and
Ileum
perforations
Small Bowel perforation

10. Sigmoid perforation,
What to do?
To do or Not to do
diverting colostomy?

11. Procedure and postoperative course
• Primary repair of the three perforations with extraction of the foreign
bodies done, and no colostomy.
• The patient discharged on Day 4.
• Good general condition.
• No complications.

12. Discussion
A variety of foreign bodies are ingested unintentionally during rapid eating, particularly by
persons with reduced palate sensitivity . Young children, elderly and mentally challenged people
are usually at a higher risk.
Ingested foreign bodies may perforate anywhere along the GI tract ,but more commonly in
the anatomical or physiological narrow or curved areas.
In order to identify site and cause of a GI perforation a CT scan of the abdomen and pelvis
before and after iv administration of contrast should be preferred over a Ct scan with oral
contrast. In fact, in the emergent setting, the study should not be delayed trying to administer
oral contrast, moreover the use of oral contrast during CT can make more difficult to detect a
radiopaque foreign body.

13. • Surgical repair of gastrointestinal perforation depends on many factors:
- The site of the GI tract perforation (esophagus, stomach, duodenum, colon, rectum…etc)
- The size of the perforation and the percentage of the circumference affected by the perforation.
- Grade of intrabdominal infection, peritonitis, stability, sepsis ...etc
- Whether the site of perforation has healthy tissues or not.

14. CONCLUSION
• Intestinal perforation secondary to a foreign body is quite rare and the surgeon
needs a high index of suspicion to do a proper diagnosis.
• CT scan of abdomen and pelvis is useful to make a proper diagnosis, but it can
delay the prompt management of a perforation.
• Surgical management of intestinal perforation depends on the site , size of the
perforation and the grade of intraabdominal contamination, in addition to the
healthiness of the tissues.

15. Thank You…