Delayed presentation of a small bowel perforation secondary to an ingested denture
A 64-year-old Caucasian woman complaining of a two-day history of acute abdominal pain with associated emesis was admitted as an emergency to our surgical unit. She had not opened her bowels or passed flatus for two days. On examination the abdomen was distended with generalized peritonitis. Digital rectal examination was unremarkable. She was hypothermic with a heart rate of 120 and a systolic blood pressure of 70 mmHg. Routine blood investigations revealed haemoglobin of 10.4 g/dL, white blood cells of 2.84 × 109/L and a C-reactive protein of 428 mg/L. Arterial blood sampling revealed a pH of 7.22, a base excess of –14.6 and a lactate of 10.8 mmol/L. Her past surgical history included a hysterectomy in 1981. Medical co-morbidities included hypertension.\nThe patient had been admitted three months earlier, and treated conservatively, for small bowel obstruction secondary to an accidental ingestion of her denture bridge two months prior to this. On the previous admission, a computed tomography (CT) of the abdomen and pelvis suggested that the bridge was within the caecum (Figures a and b). Several days later the obstruction had resolved with conservative management. Repeat plain abdominal X-ray films suggested that the denture had passed from the caecum (Figure c) into the sigmoid colon (Figure d). It was thus felt at that time that it would pass spontaneously. The patient remained completely asymptomatic until the acute presentation.\nDespite aggressive fluid resuscitation, the patient continued to deteriorate and it was decided to perform an emergency laparotomy. Intraoperatively, an ileal perforation 40 cm from the ileocaecal junction was found with minimal faecal contamination. The small bowel perforation was secondary to denture erosion through the wall of the small bowel, with non-viable distal small bowel. A limited right hemicolectomy and small bowel resection was performed, with an end to end hand-sewn ileo-colic anastomosis. The patient developed a postoperative ileus, but otherwise made a good postoperative recovery and was discharged back to the community.