Summary: A 29-year-old man without significant past medical history presented to
the Emergency Department with right lower quadrant abdominal pain and
back pain, fever, anorexia, nausea and vomiting. On physical examination
there was tenderness in McBurney’s point. Laboratory data revealed mild
leukocytosis of 13,300 per mm3. CT of the pelvis was obtained with IV and oral contrast and supplemented with coronal reconstructions.
Ruptured appendicitis with an intraluminal foreign body (calcification around a metallic paperclip)
Contrast-enhanced CT of the pelvis with coronal reconstructions
demonstrated a thickened and inflamed appendix in retrocecal position. A
3.2 cm appendicolith was present within the appendiceal lumen. Review
of the coronal images in bone windows revealed a metallic paperclip in
the center of appendicolith. Additionally, a small amount of free fluid
was localized around the inflamed appendix, consistent with
perforation. On questioning, patient did not recall foreign body
The first appendectomy was performed in 1736 at Westminster Hospital
in London on an 11-year-old boy. At the time of surgery, a sewing pin
was found to have perforated appendix.1
Foreign body appendicitis is uncommon but well described. It occurs in 0.0005% of cases of appendicitis.1–5
Various objects have been reported in the literature, including bird
shot, air gun pellets, bullets, pins, needles, teeth, dental drill bits,
toothpicks, bone fragments, fish-bone, fruit seeds and pits, chewing
gum, gallstones, fishhooks, keys, coins, gastric tube and condom
fragments, tongue studs, earrings, necklace, intrauterine contraceptive
device.1–3 Once the foreign body is lodged in the appendix,
peristaltic motion is insufficient to expel it back into the cecal
lumen. It may perforate immediately or progress to obstruction depending
on morphologic characteristics. Long, pointed, thin,stiff, sharp and/or
metallic objects are more prone to cause perforation and are defined as
risky. Blunt, smooth, round, soft foreign bodies such as seeds, hair,
enteroliths carry less risk of causing perforation but are frequently
responsible for total obstruction resulting in acute or chronic
appendicitis or an appendiceal mucocele.3,5 Additional
complications resulting from retention of foreign bodies in the appendix
can include fistula formation, development of intraabdominal and liver
abscesses, fecal peritonitis and clinically significant lead
intoxication when large numbers of shotgun pellets or bullets are
present.1–4 The latter is common in people consuming wild game.
foreign bodies in the appendix are rare, reported management varies.
Known, asymptomatic foreign bodies that are associated with high risk of
perforation may be retrieved via endoscope or removed via laparoscopy
with appendectomy, cecotomy or ileotomy.1,3 Elective
prophylactic removal of the appendix may be indicated even in patients
with low risk foreign bodies. Surgical or endoscopic intervention should
also be considered for retained lead objects to prevent chronic lead
This patient underwent laparoscopic
appendectomy. Surgical pathology revealed a perforated gangrenous
appendix with large,impacted, friable intraluminal appendicolith in the
distal portion. The fecalith was sectioned and no metallic fragments
were identified. The striking similarity of the internal structure of
the appendicolith to a paperclip on CT gives rise to speculation that
the metallic paperclip underwent longterm chemical corrosion. The
patient did not recollect any history of foreign body ingestion and
probably had the paperclip lodged in the appendix since early childhood.
Foreign bodies are rare causes of appendicitis. Rigid and/or sharp
objects have the greatest potential for appendiceal perforation.
Prophylactic appendectomy has been advocated after discovery of an
appendiceal foreign body, particularly a sharp pointed object.
- Larsen AR, Blanton RH. Appendicitis due to bird shot ingestion: A case study. Am Surg. 2000;66:589-591.
- Mincheff TV. Bullet fragment within the appendix: A case report. JSC Med Assoc. 2004;100:270-273.
- Klinger PJ, Seeling MH, DeVault KR, et al. Ingested foreign bodies within the appendix: A 100-year review of the literature. Dig Dis. 1998;16: 308-314.
- Sukhotnik I, Klin B, Siplovich L. Foreign-body appendicitis. J Pediatr Surg. 1995;30:1515-1516.
Shake JG, Kronz JD, Rodeberg DA, Colombani PM. Foreign bodies within
the appendix: A case report and literature review. Contemp Surg, 2000;