Clinical Challenges

June 2018 - What's your diagnosis?

Publish date: May 31, 2018

A 63-year-old woman with a 6-year history of fibrostenotic ileocolonic Crohn's disease (CD) presented for evaluation after multiple hospitalizations for recurrent small bowel obstruction (SBO). Treatment for CD included adalimumab and azathioprine. Before initiation of these medications, she had undergone a 30-cm ileal resection for partial SBO secondary to a fibroinflammatory ileal stricture. She had no other coexistent medical conditions.

She denied nonsteroidal anti-inflammatory drug use, but did take acetaminophen for intermittent low back pain. Family history was notable for a daughter with CD. The patient denied use of alcohol, tobacco, or illicit drugs.

Over the past year, she has been hospitalized three times for partial SBOs that were treated conservatively. Her most recent hospitalization was 1 month ago, after which she was referred for assessment of inflammatory CD as the cause of recurrent SBO. She continued to complain of intermittent left lower abdominal pain after hospital discharge. Physical examination revealed a mildly distended abdomen with positive bowel sounds, tenderness to deep palpation in the lower quadrants, and no tympany to percussion or peritoneal signs. Laboratory evaluation, including complete blood count and basic metabolic profile, was unrevealing. Inflammatory markers, including erythrocyte sedimentation rate and C-reactive protein, had been within normal limits over the past year. On review of the abdominal computed tomographic (CT) images performed during the episodes of partial SBO, there was a transition point localized on the left lower quadrant; no mural enhancement or bowel wall thickening was seen.

Reevaluation with noncontrast CT of the abdomen showed resolution of previous acute obstruction. An enteroclysis tube was then placed and a second set of images demonstrated a curvilinear density in the left lower quadrant (Figure A, arrow), in the area of prior obstructions, which was not present on previous imaging studies.

What is the most likely cause of her recurrent SBOs?


 

By Guilherme Piovezani Ramos, MD, Seth Sweetser, MD, and John B. Kisiel, MD

Recurrent SBO owing to contained perforation after accidental ingestion of a metal bristle of a barbecue grill brush

SBO may be caused by a variety of intrinsic or extrinsic lesions. Postoperative adhesions (60%) and malignant tumors (20%) are responsible for the majority of cases in the United States. CD accounts for approximately 5% of all SBOs. 1 The unusual root cause of our patient's SBO was unintentional ingestion of a foreign body.


The CT image in Figure A shows an extraluminal foreign body in the left lower quadrant, surrounded by soft tissue thickening which represents reactive granulation tissue. She underwent surgical exploration, which revealed a single adhesion from a loop of the midjejunum to the neighboring mesentery (Figure B) that, when lysed, uncovered a small metal fragment consistent with a wire bristle from a grill-cleaning brush (Figure C). On further history, she reported frequent outdoor residential food grilling and admitted to using a wire grill cleaning brush. It is likely that she unintentionally ingested a metal bristle from a barbecue grill brush that was embedded in cooked food and penetrated through the small bowel wall, causing an adhesive inflammatory reaction and subsequent recurrent SBO.

Ingested foreign bodies are most frequently encountered in the pediatric population. Injury from inadvertent ingestion of wire grill cleaning brush bristles is being reported with increasing frequency in adults. 2 Gastroenterologists should be aware of this type of foreign body injury to help prevent delay in diagnosis and ultimately treatment. This case highlights several additional important points. First, the evaluation of SBO must begin with a broad differential diagnosis, even in a patient with established CD. Second, the bristles are small and difficult to visualize on imaging. After resolution of acute obstruction, diagnostic imaging should be performed without positive oral contrast agent, which can obscure subtle mucosal findings or in this case, a diminutive extraluminal foreign body. Finally, greater public awareness should be raised that bristles might dislodge from wire grill brushes and embed in cooked food. 3

References:
1. Hayanga AJ, Bass-Wilkins K, Bulkley GB. Current management of small-bowel obstruction. Adv Surg. 2005;39:1-33.
2. Harlor EJ, Lindemann TL, Kennedy TL. Outdoor grilling hazard: wire bristle esophageal foreign body - a report of six cases. Laryngoscope. 2012;122:2216-8.
3. Centers for Disease Control and Prevention (CDC). Injuries from ingestion of wire bristles from grill-cleaning brush - Providence, Rhode Island, March 2011-June 2012. MMWR Morb Mortal Wkly Rep. 2012;61:490-2.

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