A Case of the Missing Ring

Abstract

Introduction: The ingestion of foreign bodies is most frequently observed in children and in adults with underlying psychiatric disease. Foreign bodies generally cause little morbidity if properly managed. Roughly 90% of foreign bodies pass through the gastrointestinal tract with 10-20% requiring endoscopic removal and up to 1% requiring surgical intervention. The diagnosis is usually apparent from a patient's clinical history; however, radiographs of the neck, chest and abdomen may be required in the case of patients that are poor historians. Case: The patient is a 51 year old asymptomatic man status post appendectomy in 2000 who presented for outpatient index average risk colorectal cancer screening in June 2017. He subsequently underwent a colonoscopy during which a stricture was found to be causing moderate obstruction in the ascending colon that was not traversable with an adult colonoscope. There was evidence of mucosal scarring at the site. Several cold forcep biopsies were taken, revealing colonic mucosa with rare focal active colitis and prominent lymphoid aggregates. A CT scan of the abdomen/pelvis with IV contrast was performed which revealed moderate stool burden and an indeterminate 2.5 cm metallic ring in the lumen of the terminal ileum at the ileocecal valve with associated small amounts of mural edema and inflammation involving the ileocecal valve and adjacent terminal ileum. The patient was subsequently admitted and colorectal surgery was consulted. Given the risk for erosion and obstruction, the patient was taken to the operating room for surgical resection. An ileocecectomy was performed, in which 12.5 cm of a single segment of bowel was resected and a side to side ileo-colonic anastomosis was created. Discussion: The treatment of foreign bodies is largely dependent on the foreign body ingested, location, and time since ingestion. The vast majority of foreign bodies will pass on their own; however, some do require endoscopic or surgical intervention given the risk of obstruction or erosion with subsequent perforation. The case as described above is a classic example of foreign body ingestion in which surgical intervention was indicated.1618_A Figure 1. Stricture- Stellate scar1618_B Figure 2. CT abdomen- ring at ileocecal junction