The management of gastrointestinal (GI) foreign bodies is routine observation. Sequential radiographs and stool follow-up are performed to confirm passage, unless it involves FB in the esophagus (FB lodged here should be removed), or FB consisting of batteries, sharp objects, long objects or magnets [7]. The majority of ingested FBs with a diameter less than 2.5 cm and a length less than 6 cm will within 5 days spontaneously pass through the gastrointestinal tract with excretion in the stools [8]. If they lodge in the intestines, it occurs around the curvature of the first part of the duodenum (duodenal sweep) and the physiologic narrowing just before the ileocecal valve [9].
In extremely rare cases, FBs may settle in the vermiform appendix [10,11,12,13,14,15,16]. These cases have been estimated to occur in 0.005% of ingested FBs [8]. Dr. Claudius Amyand performed the first successful appendectomy, at St. George’s Hospital in London 286 years ago. The culprit was a swallowed pin lodged in the appendix causing perforation in an 11-year-old boy [17]. This is the first reported case in Saudi Arabia of an earring trapped in a pediatric appendix undetected for 2 years. The pathophysiology is not entirely clear, but it is believed that the characteristics of the FB plays an essential role in the occurrence of symptoms similar to acute appendicitis. If the FB is heavier than fecal matter, it may settle in the appendix due to gravity. The irregularity of the FB shape may also impede their evacuation by the peristaltic movements of the appendix. The size of the FB could occasionally obstruct the opening of the appendix. Examples of easily ingested objects that fit the above descriptions include balloons, toys with small parts, doll accessories, coins, safety pins, paperclips, pins, marbles, small balls, nails, bolts, and screws, erasers, batteries, broken crayons, jewelry (rings, earrings, pins, etc.), small magnets and small caps for bottles. Another factor contributing to this rare event is the relatively weak appendiceal peristalsis [8].
When a FB lodges itself, inflammation and edema are likely to occur as a result of increased intraluminal pressure leading to appendicitis. The consequences from not recognizing and failure to appropriately manage the early presentation may lead to complications varying from local infection, obstruction, perforation, peritonitis, septic shock and death. However, the course of these events does not develop suddenly, there may be signs that indicate something is brewing, starting from pain and tenderness over the RLQ to fever and abdominal distention and peritoneal signs.
Pediatric ingestions most commonly occur in the six months to six-year age range [9, 18,19,20] (https://columbiasurgery.org/news/2015/06/04/history-medicine-mysterious-appendix). FB ingestion usually is initially asymptomatic in the pediatric population. Some FB may remain for long periods of time as in this case of a 2-year duration. Of note, 38% have reported recurrent pain for greater than a period of 1 month [5]. The majority of FB have an easy passage through the gastrointestinal tract. Nevertheless, the risk of complications remains present and proper management should be pursued. Most foreign bodies in the GI tract are radiopaque, therefore plain radiography as the first investigation is often diagnostic [21, 22]. When plain films are non-diagnostic, follow-up contrast radiography or CT is recommended [7]. In the majority of cases of trapped FB in the appendix, the X-ray does not show the specific location of the FB. With acute symptoms or a failed colonoscopy, laparoscopic exploration with the aid of the fluoroscope is the next course of action needed for the removal of the foreign objects [23, 24]. In this case, laparoscopy was preferred over colonoscopy for the following reasons; the prolonged time period between the FB ingestion and the serial diagnostic X-rays that suggested that the FB was not moving and the location of the FB; the high index of suspicion that the sharp pin-like object was trapped in the appendix; and the parents exaggerated perceived additional financial burden and risks of a CT and colonoscopy. The standard of care in such cases is serial diagnostic X-rays, followed by CT localization, if the FB is no longer migrating. Colonoscopy is initially recommended if the FB is found to be distal to the terminal ileum [23]. If the patient presented with acute symptoms or a failed attempt of retrieval via endoscopy, classical laparotomy and laparoscopic procedures are preferred [24] with or without the aid of intraoperative imaging. Identifying the exact location of the FB can save the patient unnecessary surgical exploration.
These cases have also been reported in adult patients [23], mainly found in the elderly, alcoholics, psychiatric patients, and prisoners [7]. In contrast to pediatric cases, adults are more likely to present with symptoms. It can be equally dangerous in adults as in children; however, not as prevalent.