A man swallowed a bone, and‬ 15 years later, doctors found it in his appendix — Diagnostic dilemma

The patient: A 45-year-old man in Italy

The symptoms: The man went to the emergency room because he had a sharp pain in his lower-right abdomen.

What happened next: When doctors examined the man, the type of pain and the location of his discomfort suggested that he might have appendicitis, or inflammation of the appendix.

Appendicitis can be dangerous because it can cause the appendix to burst and release bacteria from the bowels into the abdominal cavity, thereby infecting the cavity’s lining. This infection, called peritonitis, can spread to the bloodstream and cause the life-threatening condition sepsis, which kicks the immune system into overdrive.

Even though the patient had acute pain in his lower-right abdomen, he did not show signs of peritonitis, such as fever, nausea, symptoms of dehydration and an elevated heart rate, according to a report of his case. His doctors then performed abdominal ultrasound scans and found that the man’s abdominal organs, including the appendix, appeared normal, with no signs of inflammation.

The report’s authors did not include details about the man’s treatment after this examination. But eight months later, he was still in pain and returned to the hospital for further evaluation, they noted.

The diagnosis: This time, when medical personnel questioned the man, he recalled that approximately 15 years earlier, he had accidentally swallowed a piece of a long bone containing edible marrow. The report does not mention if the man sought treatment immediately after swallowing this bone.

At this second visit, doctors performed an abdominal X-ray and found a round object near the upper right of the man’s pelvis. It measured about an inch (2.5 centimeters) long and a little over an inch (3 cm) wide.

According to a subsequent CT scan, the object contained bone tissue and was near the appendix. When the doctors looked inside the patient’s abdomen with a laparoscope — a long, flexible tool with a camera at one end — they saw that the appendix was enlarged.

The treatment: Surgeons performed a laparoscopic appendectomy, which uses small incisions in the abdomen to insert instruments for removing the appendix. Inside the appendix was a hardened mass of fecal matter, called a fecaloma, which surrounded a long bone.

The organ’s muscular walls had been stretched out by the mass, but there were no signs of inflammation. No complications developed after the surgery, and the patient was discharged two days later. The report does not describe any follow-up visits or treatments.

What makes the case unique: It’s relatively uncommon for people to accidentally swallow something indigestible and then require a medical visit for it. In the United States annually, about 120,000 people — roughly 90% of whom are children — are treated for ingesting foreign objects, and most of the objects are swallowed accidentally. Most commonly, the adults requiring treatment have ingested jewelry, while children are more likely to swallow coins, toys and batteries.

Typically, small, swallowed items pass harmlessly through the intestines within 48 hours; less than 1% require surgical intervention. Some objects, however, need immediate attention. For example, sharp items can tear the esophagus or puncture digestive organs. Batteries are hazardous if swallowed, as they contain corrosive acid that can leak into the gut. And small magnets are a big risk, especially if two or more are involved, since they may stick together through intestinal walls, which can tear holes in tissues or cause blockages and contortions in the intestines.

Swallowed foreign bodies rarely affect the appendix. Whether they enter the organ depends on the size of the opening into the appendix where it connects to the colon (which can vary between individuals), the dimensions of the ingested object, and the appendix’s position in the body at the time. These objects cause approximately 0.005% cases of appendicitis, according to the man’s case report. Such items recovered by surgeons through appendectomies include pieces of coal, nails, bits of enamel and glass, shells, dental crowns and bullets.

When a foreign body migrates to the appendix, it typically generates appendicitis within a few months, at most. However, this is not always the case. One report described a man who had eaten pigeons as a child and discovered more than 30 years later that he had 27 lead shot pellets in his appendix. Despite containing these pellets from the birds’ flesh, his appendix was not inflamed.

“It is therefore possible, although rare, that a foreign body in the appendix even after many years (in our case, 15 years) does not lead to an authentic appendicitis either histologically or clinically,” the authors of the marrowbone case report wrote.

They added that their patient was the first record in the scientific literature of a sizable bone lingering inside an appendix for more than a decade without causing significant inflammation. His pain was likely caused by physical shifting of the hard mass. His experience presented “a unique clinical picture,” the doctors wrote.

“This case could offer a possible diagnostic and therapeutic option for appropriately treating patients with foreign bodies within the appendix,” they said.

For more intriguing medical cases, check out our Diagnostic Dilemma archives.

Can you guess the diagnosis in these strange medical cases? Find out with our diagnostic dilemma quiz!