Summary: 10. The pain varied from dull to sharp in character. He
initially presented to his university's health center for
evaluation. He reported that an ultrasound was performed, which was
unremarkable. The patient described worsening abdominal symptoms,
which prompted further evaluation. He noted some initial diarrhea
at the onset of symptoms, but no nausea or vomiting. Also, he
reported fevers for the last week up to 103ºF with sweats and
myalgia. During the evening prior to presenting to the emergency
room, the patient's pain localized to the right lower quadrant. The
patient was otherwise generally healthy except for some mild reflux
symptoms and depression. At the time of presentation to the
emergency room, the patient's blood pressure was 126/78 mm Hg, his
heart rate was 81 bpm, his respiratory rate was 18 breaths per
minute, and his temperature was 36.4ºC. A clinical examination
revealed a soft, nontender, nondistended abdomen, with no
hepatosplenomegaly. There was moderate tenderness to superficial
and deep palpation as well as fullness in the right lower quadrant.
There were no peritoneal signs. His stool was hemenegative.
Laboratory results, including complete blood count, chemistries,
and urinalysis were all negative.
Inflammation of the terminal ileum secondary to an embedded plastic
sword with ulceration in the ascending colon
In the emergency room, CT scans of the abdomen and pelvis were
ordered, which revealed inflammatory changes and diffuse thickening
of the terminal ileum (Figures 1 and 2). The length of the involved
segment of the terminal ileum measured approximately 10 cm. The
cecum and appendix were normal in appearance. The diagnosis
provided by the radiologist was Crohn's disease and the
differential diagnosis included infectious (Yersenia)
neoplastic (lymphoma) etiologies.
The working diagnosis was Crohn's disease, and the patient was
admitted to the hospital. A gastroenterology consultation was
requested. During this evaluation, it was discovered that the
patient had been at a bar approximately 10 days before presentation
to the emergency room. He recalled swallowing a spearlike
mixed-drink plastic sword pick. The patient stated he was uncertain
why he did this but reported symptoms of pain 3 to 4 days after
Based on the history, a colonoscopy was performed, which
revealed a plastic sword pick with the tip and blade in the
terminal ileum and the hilt embedded in the proximal ascending
colon. The sword was removed cautiously during the colonoscopy. A
localized area of mucosa in the terminal ileum was mildly
erythematous and nodular. A single 6-mm ulcer was found in the
proximal ascending colon at the embedded site.
The differential diagnosis for inflammation and wall thickening
of the terminal ileum is extensive, including inflammatory,
infectious, and neoplastic processes. In a young adult, the most
common etiology is Crohn's disease. However, with the right
clinical history, foreign bodies should also be considered.