An Unusual Case of Duodenal Perforation Caused by a Lollipop Stick: A Case Report
A 23-year-old woman presented to the emergency department of our hospital with epigastric and right upper quadrant pain that started 2 days ago. She had no significant medical history and not taking any medicine. Physical examination revealed epigastric and right upper quadrant tenderness, with rebound tenderness in the right upper quadrant. Her vital signs were as follows: blood pressure, 130/90 mm Hg; heart rate, 78 beats per minute; body temperature, 36.6℃; and respiratory rate, 18 breaths per minute. Plain radiographs of the abdomen did not reveal any abnormal findings. Laboratory tests revealed a white blood cell count of 12,800/mm3 (neutrophil, 81.7%); hemoglobin level of 11.4 g/dL; platelet count of 175,000/mm3; and C-reactive protein level of 10.7 mg/dL (reference limit, 0.1 to 1 mg/dL). Liver function tests, renal function tests, and electrolytes were all within the reference limits. An abdominal CT scan revealed a 7-cm-long, stick-like foreign body situated vertically from the duodenal bulb to the third portion of the duodenum. Mottled air density and blurred periduodenal fat planes with streaky soft tissue stranding were also observed around the third portion of the duodenum; however, no pneumoperitoneum was observed (). The patient was unaware of ingesting the foreign body. Emergency esophagogastroduodenoscopy was performed to identify the foreign body. A surgical team was contacted to ascertain whether emergency surgery could be carried out immediately if bowel perforation is detected during esophagogastroduodenoscopy or if the abdominal pain becomes worse. A lollipop stick was found in the duodenum, with a shallow ulcer in the proximal third portion of the duodenum, and it was endoscopically removed with rat-tooth forceps. Two small ulcers, one proximal with exudates and the other distal with air bubbles, were also seen in the third portion of the duodenum. Successful closure was performed by placing 3 hemoclips (HX-610-135; Olympus, Tokyo, Japan) to the proximal ulcer. Five hemoclips were placed circumferentially around the perimeter of the perforation edge of the distal ulcer. A detachable snare (SD 6L-1; Olympus) was placed around the perimeter base of the clips. The snare was then tightened, successfully bringing all the edges of the wound together (). The patient recalled having slept drunk with a lollipop in her mouth 2 weeks previously. The next day, abdominal CT was repeated to observe the hemoclips in the duodenum and the periduodenal inflammation; however, no pneumoperitoneum was yet observed. An intravenous proton-pump inhibitor and antibiotic treatments, including metronidazole and a third-generation cephalosporin, were used, and she was placed on a nothing-per-oral status with nasogastric tube drainage for 5 days. From the sixth day of hospitalization, feeding was gradually advanced from water to a liquid diet, and then to a soft diet. She refused to undergo follow-up endoscopy and was discharged on the ninth day of hospitalization. She remained asymptomatic at the subsequent follow-up 2 weeks after discharge.