Small bowel perforation due to chicken bone, with incidental gastric leiomyoma

Case contributed by Dr Michael P Hartung

Presentation

Developmental delay. Abdominal pain. Recent consumption of chicken wings.

Patient Data

Age: 50 years
Gender: Male

Delayed phase images were obtained due to motion on portal venous phase. Portal venous phase imaging is included in this case to highlight the gastric findings.

Best seen on delayed phase imaging, there is focal thickening and hyperemia associated with a loop of small bowel in the right lower abdomen. A bone fragment can be seen within the bowel lumen, with the pointed edges of the fragment protruding into the wall. Proximally, an additional fragment of thin bone can be seen within the small bowel lumen.

On the portal venous phase imaging, there is a round intramural mass in the gastric fundus. It has peripheral enhancement and central low attenuation. At the time of initial imaging, this was felt to represent a focal intramural perforation/abscess in the stomach due to the ingestion of chicken bones.

Specimen: Small bowel with bone

Gross: Received fresh is an opened, 15.0 cm segment of small bowel with attached mesenteric fat extending the length, averaging 2.5 cm. The pink-tan serosa is smooth, glistening, and mildly congested. The entirety of the mucosa is mildly to severely edematous. There are two separate areas of mucosal ulceration and erythema which are 6.0 cm apart and as close as 3.5 cm from the nearest margin. The largest area of ulceration is 3.5 x 1.0 cm, with the opposite area being 1.5 x 0.5 cm. The areas both have some thin, yellow-green exudate. There is no transmural perforation identified. The mesenteric fat is edematous, but otherwise unremarkable. The container has two calcified fragments of tissue, consistent with bone (3.0 x 1.0 x 0.6 cm and 1.6 x 0.3 x 0.2 cm).

Diagnoses:

Small intestine, resection - Segment of small intestine harboring two fragments of bone consistent with ingested foreign bodies, complicated by acute enteritis with ulceration, perforation, and intramural abscess.

Distal esophageal distention by ingested material, likely food impaction. Persistent peripherally enhancing, centrally low attenuation intramural mass in the gastric fundus. Changes of small bowel resection from chicken bone perforation. No other acute findings.

Specimen: Gastric cardia lesion

Clinical History: Submucosal mass within gastric fundus.

Operation/Procedure: Endoscopic ultrasound with FNA

Comment: The spindle cell lesion is of relatively low cellularity, with no atypia or mitotic figures. There is associated hyalinized fibrosis and inflammation, consistent with central lesional degenerative changes.

Given the size (2.6 cm) and the morphology of the sampled biopsy material, this is likely a leiomyoma (rather than leiomyosarcoma). Repeat biopsies might help in more conclusively ruling out sarcoma.

Diagnoses:

Gastric cardia lesion, biopsy:

  • Mesenchymal neoplasm with smooth muscle differentiation (see comment).

  • Accompanied with abscess with inflammatory cells and granulation tissue.

Case Discussion

This case provides a great example of small bowel perforation due to chicken bone ingestion. There are two separate fragments of chicken bone within the small bowel, both of which were present in the pathologic specimen.

What makes this case particularly interesting is the mass in the gastric fundus. Given that it had peripheral enhancement and central low attenuation, an intramural abscess or perforation was favored due to the ingestion of chicken bones. However, this finding persisted on the follow-up study, which made it suspicious for mesenchymal neoplasm such as gastrointestinal stromal tumor. The final pathologic diagnosis is gastric leiomyoma, with abscess and inflammation.

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Case information

rID: 59948
Published: 1st May 2018
Last edited: 2nd May 2018
Inclusion in quiz mode: Included

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