Chicken bones: An etiology of a misleading clinical presentation of a rare case report of appendicular perforation

Abstract

Foreign body (FB) ingestion leading to appendicular perforation, although rare in adults, presents a complex clinical challenge. The clinical presentation may not always be straightforward, necessitating a comprehensive array of diagnostic examinations. In fact, accurate and timely diagnosis is crucial to prevent severe complications. In this report, we present a case where a misleading clinical presentation led to the unexpected discovery of appendicular perforation during surgery, despite initial suspicion of small bowel perforation – a 77-year-old male patient who was edentulous and under follow-up for chronic bronchitis stage IV. He sought medical attention due to a 2-week history of right iliac fossa pain, during which he did not experience vomiting or fever. Upon physical examination, there was a tenderness noted in the sub umbilical region. An abdominal computed tomography (CT) scan was performed, revealing the presence of a dense FB which seems to be a bone located in the last ileal loop. Additionally, the appendix appeared slightly distended. Given the clinical presentation, which strongly indicated acute peritonitis resulting from small bowel perforation, and following consultation with gastroenterologists, it was decided that endoscopic retrieval was not suitable for this case. Therefore, a surgical approach was chosen, involving a midline incision, as laparoscopy was absolutely contraindicated because of patient’s respiratory distress. Per-operatively, we identified a clear effusion, and within the wall of the appendix, we discovered a thin, sharp chicken bone that had become lodged, resulting in a phlegmonous and perforated appendix. The 2-cm bone was successfully removed, and an appendectomy was performed. The post-operative period was uneventful, and the patient was discharged on the fourth postoperative day. This case highlights the need for a high index of suspicion for atypical clinical presentations and the ongoing need for research to improve our understanding and management of this rare condition, ultimately enhancing patient outcomes.