A rare mode of entry for needles observed in the abdomen of children: Penetration.

REPORT OF INCIDENTALLY DETECTED SEWING NEEDLES ON PLAIN ABDOMINAL RADIOGRAPHS IN TWO PATIENTS WITHOUT ANY PRIOR HISTORY OF INGESTION OR OF BEING PIERCED: one in the liver and the other in the peritoneum encased by omentum. These case reports point out a rare mode of entry of needles into the abdominal cavity by penetration from outside.

INTRODUCTION

Ingestion and detection of foreign bodies within the abdomen is a common occurrence in children.[1-3] Foreign bodies can enter the body cavities not only through ingestion, but also through a penetrating injury.[4]

CASE REPORTS

Case 1

A 4-year-old female was admitted with abdominal pain of 24 h duration. She had nausea without vomiting and fever. He was able to pass stools and flatus. The physical examination was unremarkable other than mild epigastric tenderness. An image of a foreign body (sewing needle) was observed in the right lower quadrant in the upright abdominal radiograph (SAXR) and in the midline near the anterior abdominal wall in the lateral abdominal radiograph [Figure 1]. No history related to ingestion of or being pierced by a foreign body could be obtained even after careful questioning of the family.

Figure 1

Plain abdominal radiograph shows a needle (arrow) in the abdomen. Lateral abdominal view (small picture) shows a metal point near the anterior abdominal wall (circle)

During the exploratory laparotomy, a corroded, fragile sewing needle within the omentum wrapped with a robust fibrotic tissue (inflammation) was detected in the peritoneal cavity. The needle was not in direct contact with the intestines and was removed along with the surrounding omental mass. The postoperative recovery was uneventful.

Case 2

A 14-year-old male patient was admitted with a 1 day history of abdominal pain and vomiting. The patient was referred to our center upon detection of a foreign body (sewing needle) in SAXR. The physical examination in our emergency room was consistent with acute appendicitis, with an elevated white blood cell count. SAXR images were consistent with a foreign body (sewing needle) in the upper-right abdominal quadrant, and abdominal ultrasonography was indicative of acute appendicitis. Abdominal computed tomography revealed a sewing needle in the right hepatic area and an image consistent with acute appendicitis. The abdomen was explored through a right paramedian incision and an appendectomy was performed.

The foreign body seen in preoperative radiological studies was not in the appendix or intestinal lumen; fibrosis or adhesions that might be a result of possible previous passage of a needle was detected in these areas. Intraoperatively, the needle was located with the help of fluoroscopy, which showed that the needle was embedded nearly 1 cm into the hepatic parenchyma and parallel to the lower edge of the right hepatic lobe. It could not be seen or palpated from outside. It was exposed by opening the overlying liver parenchyma with electrocautery [Figure 2]. The severely corroded needle totally embedded in the hepatic parenchyma and encased by fibrosis could not be removed by manual extraction and easily broke. It was totally removed in two pieces by incising the liver parenchyma parallel to the axis of the needle. There was no fibrosis or adhesions on the lower surface of the liver. The patient has remained asymptomatic at one year follow-up.

Figure 2

A rusty, embedded needle in the liver. Extracted broken needle is seen on small picture

DISCUSSION

Sharp foreign bodies enter the abdominal cavity not only through the digestive tract, but also by penetration through the abdominal wall.[4-8] Entry by penetration was more frequently reported for foreign bodies in the thoracic cavity.[910] Foreign body penetrations can occur by accident, self injury or physical abuse.[4910] Sharp foreign bodies can reach the liver by three routes: direct penetration from the abdominal wall; migration through the digestive tract; migration through blood circulation.[11] Taking into account the localization, position and the severely corroded condition of the needle in the liver in the second case (presented with no prior history of injury), it is reasonable to assume that the needle most likely entered the body from the dorsal area accidentally during infancy and the injury was not noticed by the parents at that time.

Both of these cases had no history regarding ingestion of a foreign body. The radiological and surgical findings led us to consider that penetrating injury was responsible for the foreign bodies in both cases. There were no fibrotic findings or adhesions attributable to migration from adjacent organs. Plain radiographs may thus be useful in evaluation of chronic abdominal pain in children.