An Unusual Cause of Abdominal Pain: Three Lead Pellets within the Appendix Vermiformis

Abstract

Most ingested foreign bodies usually pass out in the feces uneventfully. Complications such as intestinal perforation and bleeding usually occur with sharp, thin, stiff, long, and pointed objects. This case describes the management of three lead pellets within the appendix vermiformis. A 45-year-old male visited our clinic complaining of a 4-month history of abdominal pain. The patient inquiry revealed that he had eaten hunted rabbit meat on numerous occasions and had unintentionally ingested three lead pellets. Plain abdominal films and a barium enema showed foreign bodies in the right lower abdominal quadrant. Since the lead pellets were thought to have migrated extraluminally, they were removed through laparotomy under fluoroscopic guidance. An appendectomy was performed. Pathologically, three lead pellets were embedded in the appendix, which showed signs of intramucosal inflammation. Foreign bodies causing appendicitis are rare. However, if stiff or pointed objects enter the appendicular lumen, there is a high risk of appendicitis, perforation, or abdominal pain. An appendectomy was required to remove the ingested lead pellets in the appendix.

Appendiceal Foreign Bodies in Adults: A Systematic Review of Case Reports

“…On the retrospective review of 64 case reports [5, (from 1971 to 2022) describing appendicitis induced by foreign body and fulfilling the inclusion criteria, we recorded the patient age, gender, type of foreign body, diagnostic imaging identifying the FB in the appendix, and management. Cases were reported from 25 countries, with 18 cases reported from USA [8][9][10][11][12][13][14][15][16][17][18][19], seven from UK [5,[20][21][22][23][24][25], five from Japan [26][27][28][29][30] and Korea [31][32][33][34][35] each, three from the Netherlands [36][37][38] and from Turkey [39][40][41]. Australia [42,43], Ecuador [44,45], Italy [46,47] and Taiwan [48,49] each had two cases while the rest of the following reported only one case: Austria, Cameroon, China, Croatia, France, Germany, Iran, Ireland, Kuwait, Morocco, New Zealand, Peru, Saudi Arabia, Singapore and Spain…”

Lead ammunition residues in a hunted Australian grassland bird, the stubble quail (Coturnix pectoralis): Implications for human and wildlife health

“…Due to the small surface area to volume ratio of lead pellets and large fragments, only a small proportion of the lead mass is likely to be absorbed into the bloodstream. Rare exceptions include cases where lead shot or bullets are retained in the intestinal tract resulting in elevated blood lead and/or appendicitis [ 49 – 51 ]. However, two factors mean that the risks are higher than this would otherwise imply.…”

Shotgun pellet ingestion: two cases unique to the Northern Territory

“…Ingested foreign bodies are uncommon in the adult population, being more frequently seen in the paediatric or elderly population. Perforation from foreign body ingestion is even more uncommon, complicating less than 1% of such presentations, and generally occurs in the upper oesophagus, duodenum or duodenojejunal junction, and when in the large bowel, at the ileocaecal valve, appendix or recto‐sigmoid colon 2 …”

“…Perforation from foreign body ingestion is even more uncommon, complicating less than 1% of such presentations, and generally occurs in the upper oesophagus, duodenum or duodenojejunal junction, and when in the large bowel, at the ileocaecal valve, appendix or recto-sigmoid colon. 2 Case reports of complications from pellet ingestion have been identified in the literature in the Inuit population in northern Canada who hunt and eat game meat regularly, the Alaskan population from eating waterfowl and hunters who eat rabbit meat. [3][4][5] However, these reports involve pellets localized within the vermiform appendix leading to appendiceal luminal obstruction and subsequent appendicitis.…”